HX00043702 


"RT45  C81 

Columbia  (Bntoersrttp 

College  of  iptjpsicians  ano  burgeons! 


TLibvavp 


LIPPINCOTrS  NEW    MEDICAL   serj 

Edited  by  FRANCIS  R.  PACKARD,  M.D. 

THE   MEDICAL    DISEASES 

OF 

INFANCY  AND  CHILDHOOD 


WITH  POINTS  ON  THE  ANATOMY. 
PHYSIOLOGY,  AND  HYGIENE  PECU- 
LIAR TO  THE  DEVELOPING  PERIOD 

BY 

ALFRED  CLEVELAND  COTTON,  A.M.,  M.D. 

Professor  of   Paediatrics  Rush  Medical  College,  University  of  Chicago  :     Attending  Physician  for 
Diseases  of  Children   Presbyterian  Hospital;    Consultant  to  the  Central' Free  Dispensary, 
etc.,  etc.       Formerly  Physician-in-charge  of   the  Chicago  Isolation    Hospital  and 
of  the  Infectious  Disease    Wards    of  the   County    Hospital.     Member   of 
the    XIII.   International    Medical    Congress,    Moscow.     Honor- 
ary   Member   of  the   Societe    d'Hygiene,    Paris,    etc. 


PHILADELPHIA   6-  LONDON 
J.    B.    LIPPINCOTT    COMPANY 

1906 


Copyright,  1906,  by  J.  B.  Lippincott  Company 


1^    J^' 


«L 


TO    THE     PHYSICIAN'S    WIFE 

IN  TOKEN  OF  APPRECIATION  OF  THE  UNTIR- 
ING DEVOTION  OF  A  LOVED  HELPMATE  THIS 
WORK  IS  AFFECTIONATELY  INSCRIBED  BY  THE 
AUTHOR 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/medicaldiseasesoOOcott 


Preface 


It  was  not  without  misgivings  that  the  author  acceded  to  the  request 
of  the  J.  B.  Lippincott  Company  to  prepare  a  work  limited  to  six  hun- 
dred pages  comprising  all  the  medical  diseases  of  infancy  and  childhood. 
For  want  of  space  case  records  and  temperature  charts  are  omitted, 
while  discussions  and  opinions  upon  mooted  subjects  are  necessarily 
restricted.  The  reader's  indulgence  is  asked  for  the  flavor  of  dog- 
matism, from  which  deductions  drawn  largely  from  personal  experiences 
are  rarely  free. 

The  need  of  a  more  thorough  preparation  for  the  study  of  clinical 
pEediatrics  than  is  afforded  by  a  general  knowledge  of  the  Anatomy  and 
Physiology  of  adult  life  is  so  evident  that  considerable  space  is  devoted 
to  these  subjects  with  reference  to  the  developing  period. 

Part  I  is  practically  a  revision  of  the  author's  previously  published 
Lessons  on  Anatomy,  Physiology,  and  Hygiene  of  Infancy  and  Child- 
hood. 

The  subject  of  Infant  Feeding,  always  of  paramount  importance,  is 
treated  broadly  in  the  hope  of  stimulating  a  genuine  interest  in 
principles  rather  than  a  blind  following  of  dogmatic  formulas. 

The  author  desires  to  acknowledge  the  unfailing  courtesy  and 
patience  of  the  Publishers  and  to  return  thanks  to  the  following  gentle- 
men for  reading  manuscript  and  for  valuable  suggestions:  Dr.  John 
Edwin  Rhodes,  diseases  of  the  Respiratory  System ;  Dr.  Theodore  Tieken, 
disorders  of  the  Blood  and  Glands:  Dr.  G.  W.  Hall,  diseases  of  the 
Nervous  System ;  Dr.  AY.  J.  Butler,  Heart  Disease  and  Eruptive  Fevers ; 
Dr.  J.  W.  Vanderslice,  Infant  Feeding ;  Dr.  J.  A.  Patton,  diseases  of  the 
Genito  Urinary  Tract ;  Dr.  Cassius  D.  Wescott,  for  practically  rewriting 
diseases  of  the  Eye.  To  Drs.  John  Ridlon  and  Wallace  Blanchard  for 
illustrative  cuts;  Dr.  F.  W.  Allin  for  reading  page  proof  and  arrang- 
ing index ;  Hon.  Wm.  H.  Collins  for  corrections  in  phraseology. 

Especial  acknowledgment  is  due  to  Dr.  Julia  D.  Merrill  for  valu- 
able assistance  and  advice  in  every  stage  of  the  work. 

Chicago,  January,    1906. 


Contents 


PART   I 

Anatomy,  Physiology,  and  Hygiene  of  the 
Developing  Period 

♦ 

CHAPTER    I 

ANATOMY    OF    THE    NEW-BOBN  PAGg 

The  Skin — Skull — Ear — Face — Neck — Vertebral  Column — Long  Bones — Thorax 
— Larynx — Trachea  —  Lungs  —  Heart  —  Thymus  Gland  —  Thyroid  Gland — 
Liver — Spleen — Pancreas — Kidneys — Suprarenals — Bladder — Urethra — Tes- 
ticles— Ovaries — Uterus — Mammary  Glands — Brain — Spinal   Cord 17 

CHAPTER    II 

NOBMAL  GROWTH    AND   DEVELOPMENT 

Length — Weight — Bones  of  Head  and  Face — Nasopharynx — Dentition — Vertebral 
Column — Thorax —  Lungs —  Heart  —  Blood-Vessels — Thyroid — Thymus — Ali- 
mentary Tract — Stomach — Intestines —  Liver —  Spleen — Kidneys — Bladder — 
— Uterus — Inguinal  Canal — Nervous  System    42 

CHAPTER    III 

PHYSIOLOGY   AND   HYGIENE   OF   THE   NEW-BOBN 

Circulation  of  the  Blood — Respiration — Temperature — Alimentary  Canal — Urine 
— Skin  —  Sebaceous  Glands  —  Sweat  Glands  —  Lachrymal  Glands  —  Nervous 
System — Sight — Hearing — Smell — Taste — Touch — Care  of  the  New-Born.  ...     61 

CHAPTER  IV 

PHYSIOLOGY    OF    THE    FIRST    YEAR 

Development  of  Special  Senses — Co-ordination — Cry — Speech — Standing — Walk- 
ing— Respiration — Pulse — Digestion — Feces — Urine 70 

CHAPTER    V 

HYGIENE    OF   THE   FIRST    YEAR 

Protection  and  Food — Nursery — Sleep — Clothing— Baths — Exercise   78 

CHAPTER    VI 
nYGIENE   OF   TnE   FIRST   YEAB — CONTINUED 

Food — Natural  Feeding — Rules  for  Breast  Feeding — Breast  Milk — Variations 
In  Quantity  and  Quality — Composition  of  Breast  Milk — Milk  Production — 

Colostrum  Milk    85 

vii 


vm  CONTENTS 

CHAPTER    VII 

HYGIENE    OF    LACTATION  pAGE 

Quantity  of  Milk — Conditions  Influencing  Breast  Milk — Methods  of   Changing 

The  Composition — Disturbances 96 

CHAPTER    VIII 

MILK    ANALYSIS 

Determination  of  Fat — Relation  of  Fat  to  Specific  Gravity 100 

CHAPTER    IX 

WEANING    AND    SUBSTITUTE    FEEDING 

Supplemental  Feeding — Indications  for  Weaning — Wet-Nurses    106 

CHAPTER    X 

ARTIFICIAL   FEEDING 

Food  Essentials — Development  of  Digestive  Tract  by  Food — Comparison  of  Bo- 
vine and  Human  Milk   110 

CHAPTER    XI 

ARTIFICIAL   FEEDING CONTINUED 

Percentage    Feeding — Failure    in   Percentage    Feeding — Milk    Laboratory — Milk 

Supply — Care  of  Milk— Sterilization — Pasteurization    114 

CHAPTER  XII. 

ARTIFICIAL  FEEDING CONCLUDED 

Home  Modification  of  Milk — Methods  of — Tables  and  Rules  for — Difficulties 
of  Artificial  Feeding — Constituents  of  Cow's  Milk — Objections  to  Cow's 
Milk — Efforts  at  Correction — Other  Infant  Foods — Principles  to  be 
Observed   in   Artificial   Feeding 118-132 

CHAPTER    XIII 

HYGIENE   OF    LATER   INFANCY 

Care  of  the  Mouth  and  Nasopharynx — Care  of  the  Feet  and  Legs — Develop- 
ment of  Secretions — Change  in  Diet 133 

CHAPTER    XIV 

PHYSIOLOGY    AND    HYGIENE    OF    CHILDHOOD 

Normal  Proportions — Education — Capacity  for  Attention 138 

CHAPTER  XV 

CARE    OF    THE    PREMATURE    INFANT 

The      Premature      Infant  —  Incubators  —  Feeding  —  Temperature  —  Rate      of 

Growth 145-148 

CHAPTER  XVI 

CONGENITAL   MALFORMATIONS 

Caput  Succedanoum —  Cephalhematoma —  Meningocele,  Encephalocele—  ITydr  en- 
cephalocele — Hernia  Cerebri — Congenital  Hydrocephalus — Microcephalus — 
Spina  Bifida — Malformations  of  the  Spinal  Cord— Congenital  Deformities 
of  Extremities — Malformations  of  the  Eye — Malformations  of  the  Ear — 
Hematoma  of  Sternomastoid  (Caput  Obstipum)  — Cleft  Palate  (Hare- 
lip)— Branchial  Fistula? — Facial  Defects — Malformation  of  the  Digestive 
Tract — Congenital  Dilatation  of  the  Colon  and  Stomach — Umbilical  Defects 
— Diastasis  of  the  Recti  Muscles — Diaphragmatic  Hernia — Exstrophy  of  the 
Bladder  (Ectopia  Vesicae) — Congenital  Atresia  of  Urethra,  Vulva,  and 
Vagina — Epispadias  (Hypospadias)  —  Naevi  (Birth-Marks;  Port-Wine 
Stains) — Congenital  Bony  Defects  (Osteogenesis  Imperfecta) — Achondro- 
plasia   (Chondrodystrophia  Fetalis) — Cleidocranial  Dysastosis    149 


CONTENTS  •  ix 

PART    II 

Diseases   of  Children 

¥ 
CHAPTER    I 

DISEASES    OF    THE    NEW-BORN  pAGE 

Examination  of  Children — Asphyxia — Inspiration  Pneumonia  of  the  Newly  Born 
— Cyanosis  Infantum  — Atelectasis  —  Inanition  Fever  —  Anuria  —  Sclerema 
Neonatorum — Paralysis    106 

CHAPTER    II 

INFECTIOUS    AND    HEMORRHAGIC    DISEASES    OF   THE    NEW-BORN 

Susceptibility  —  Mastitis  Neonatorum  —  Icterus  Neonatorum — Grave  Icterus  — 
Pemphigus  Neonatorum  —  Omphalitis  —  Tetanus  —  Erysipelas — Acute  Fatty 
Degeneration  (Buhl's  Disease) — Epidemic  Hemoglobinuria  (Winckel's  Dis- 
ease)— Hemorrhages — Melena — Vaginal  Hemorrhages    176 

CHAPTER    III 

DISORDERS    OF    NUTRITION 

Marasmus — Infantile  Atrophy;  Pedatrophy;  Athrepsia  ;  Simple  Wasting — Rha- 
chitis  —  Scorbutus  (Infantile  Scurvy)  — Adipositas  —  Osteomalacia — Osteo- 
psathyrosis        182 

CHAPTER    IV 

DISORDERS    OF   THE    DIGESTIVE    SYSTEM 

The  Lips,  Tongue,  and  Mouth — Perleche  (Licking  Disease  of  the  Lips) — Macro- 
glossia  (Hypertrophy  of  the  Tongue) — Acute  Glossitis — Lingua  Geographica 
(Desquamative  Glossitis;  Pityriasis  Linguae) — Ulcer  of  the  Tongue — Riga's 
Disease  —  Ranula — Tongue-Tie  (Elongatio  Frenuli)  —  Difficult  Dentition  — 
Catarrhal  Stomatitis  (Stomatitis  Catarrhalis) — Stomatitis  Aphthosa  (Sto- 
matitis Herpetica;  Vesicular  Stomatitis;  Follicular  Stomatitis;  Canker 
Sore  Mouth) — Bednar's  Aphtha?  (Aphthae  of  the  Palate) — Stomatitis 
Mycosa  (Mycetogenic  Stomatitis:  Parasitic  Stomatitis;  Thrush;  Muguet; 
Sprue;  Soor) — Stomatitis  Ulcerosa  (Ulcerative  Stomatitis:  Putrid  Sore 
Mouth) — Stomatitis  Gangrenosa  (Noma  of  the  Face;  Cancrum  Oris)  — 
Stomatitis   Membranosa — Gonorrhceal   Stomatitis 201 

CHAPTER    V 

DISORDERS    OF   THE    DIGESTIVE    SYSTEM — CONTINUED 

Diseases  of  the  Throat,  Pharynx,  and  CRsophagus — Acute  Tonsillitis — Suppura- 
tive Tonsillitis  (Phlegmonous  Tonsillitis;  Quinsy) — Follicular  Tonsillitis 
(Lacunar  Tonsillitis) — Chronic  Tonsillitis  (Hypertrophy  of  the  Tonsils)  — 
Vincent's  Angina  (Ulcero-Membranous  Tonsillitis)  — Acute  Uvulitis  — 
Pharyngitis  —  Acute  Pharyngitis  —  Chronic  Pharyngitis  —  Adenoid  Vegeta- 
tions—  Retropharyngeal  Abscess  —  Diseases  of  the  (Esophagus  —  Retro- 
esophageal Abscess   215 


x  CONTENTS 

CHAPTER    VI 

DISEASES    OF   THE    GASTEO-ENTEBIC   TEACT  PAGE 

Vomiting — Congenital  Hypertrophic  Stenosis  of  the  Pylorus;  Pyloric  Spasm — 
Acute  Gastritis  (Acute  Gastric  Catarrh;  Acute  Gastric  Adenitis) — Gastric 
Ulcer  and  Hemorrhage — Intestinal  Colic  (Enteralgia;  Neuralgia  Enterica) 
— Acute  Dyspepsia  (Acute  Indigestion) — Acute  Enteritis  (Summer  Diar- 
rhoea)— Cholera  Infantum — Chronic  Gastritis  (Chronic  Gastric  Catarrh; 
Chronic  Dyspepsia) — Amoebic  Dysentery — Incontinence  of  Faeces — Consti- 
pation— Mucous  Disease  (Chronic  Intestinal  Catarrh;  Gastro-Duodenal 
Catarrh;  Chronic  Mucocolitis;  Intestinal  Indigestion;  Tubular  Diarrhoea; 
Myxoneurosis  Coli;  Colica  Mucosa) — Intestinal  Parasites  (Worms) — In- 
tussusception— Volvulus — Appendicitis — Proctitis  and  Rectal  Ulceration — 
Prolapse  of  the  Rectum  and  Anus — Fissure  of  the  Anus — Rectal  Polypi — 
Hemorrhoids   237 

CHAPTER    VII 

DISEASES    OF   THE    LIVEE   AND   PANCBEAS 

Congestion  of  the  Liver — Acute  Infectious  Liver — Suppurative  Hepatitis  (Ab- 
scess of  the  Liver) — Cirrhosis  of  the  Liver — Acute  Yellow  Atrophy  of  the 
Liver — Fatty  Liver — Amyloid  Degeneration  of  Liver,  Kidney,  Spleen,  etc. — 
Hydatids  of  the  Liver — Tumors  of  the  Liver — Syphilitic  Pancreatitis 283 

CHAPTER    VIII 

DISEASES   OF   THE    HEAET   AND    PEBICAEDITJM 

Congenital  Diseases  of  the  Heart — Functional  Heart  Disease — Acute  Endo- 
carditis— Chronic  Endocarditis  (Chronic  Valvular  Disease) — Myocarditis 
— Adherent  Pericardium    (Chronic  Pericarditis) 289 

CHAPTER    IX 

DISEASES    OF   THE   EESPIEATOBY   TEACT 

Rhinitis,  Acute  and  Chronic  (Coryza;    Acute  Nasal  Catarrh;    Cold  in  the  Head) 

—  Membranous  Rhinitis  —  Syphilitic  Rhinitis  —  Nasal  Polypi  —  Epistaxis 
(Nose-bleed) — Congenital    Laryngeal    Stridor — Acute    Laryngitis — Chronic 

Laryngitis  —  Syphilitic  Laryngitis  —  Tuberculous  Laryngitis  —  Pseudomem- 
branous Laryngitis  (Membranous  Croup;  True  Croup) — (Edema  of  the 
Glottis — Tumors  of  the  Larynx — Foreign  Bodies  in  the  Larynx  and  Trachea 
— Tracheitis — Acute  Bronchitis — Chronic   Bronchitis — Fibrinous  Bronchitis 

—  Bronchiectasis  —  Asthma  —  Fibrinous  Pneumonia  ( Lobar  Pneumonia ; 
Croupous  Pneumonia;  Pneumonitis) — Bronchopneumonia  (Catarrhal  Pneu- 
monia; Lobular  Pneumonia;  Capillary  Bronchitis) — Chronic  Interstitial 
Pneumonia  (Peribronchitis;  Pulmonary  Fibrosis;  Fibroid  Phthisis;  Cirrho- 
sis or  induration  of  the  Lung) — Hypostatic  Pneumonia — Abscess  of  the 
Lun?  and  Pulmonary  Gangrene — Atelectasis  (Collapse  of  the  Lung) — Pul- 
monary  Emphysema — Pleuritis    (Pleurisy) 311 

CHAPTER    X 

DISEASES    OF   THE    KIDNEYS,    BLADDEE,    AND   GENITAL   OEGANS 

Anuria  and  Oliguria — Hematuria — Hemoglobinuria — Intermittent  Albuminuria 
(Orthostatic,  Postural.  Cyclic.  Functional.  Physiological  Albuminuria)  — 
Kidneys  (Malformations  and  Congenital  Anomalies  i — Acute  Nephritis — 
Chronic    Nephritis — Uric    Acid — Calculi — Pyelitis     (Pyelonephritis;      Pyo- 


CONTENTS  xi 

PAGE 

nephrosis)  — Cystitis — Perinephritis  ( Paranephritis ;  Epinephritis )  — Hydro- 
nephrosis— Balanitis,  Posthitis,  and  Urethritis  in  Male  Children — Simple 
Vulvovaginitis — Specific  Vulvovaginitis — Phimosis  and  Adherent  Prepuce — 
Eneuresis  (Incontinence  of  Urine) — Cryptorchidism  (Undescended  Testicle) 
— Hydrocele — Hydrocele  in  Cirls   3G6 

CHAPTER    XI 
DISEASES   OF   THE    NERVOUS    SYSTEM 

Convulsions  (Eclampsia;  Spasms) — Epilepsy — Tetany  (Tetanilla) — Laryngis* 
mus  Stridulus  ( Laryngospasm ;  Cerebral  Croup) — Thornsen's  Disease — 
Myotonia  Congenita  —  Hysteria  —  Catalepsy  —  Chorea — Habit  Spasm  (Tic 
Convulsif;  Habit  Chorea;  Facial  Tic) — Imperative  Movements — Spasmus 
Nutans  (Head-nodding;  Nystagmus) — Athetosis — Pavor  Nocturnus  (Night 
Terrors) — Speech  Defects — Echolalia  and  Coprolalia — Aphasia — Masturba- 
tion—  Reflexes  —  Reflex  Disorders  of  Dentition  —  Headache  —  Meningitis  — 
Tuberculous  Meningitis — Cerebro  Spinal  Meningitis — Simple  Basic  Menin- 
gitis (Infantile  Basilar  Meningitis  of  Non-Tuberculous  Origin)  Posterior 
Basic  Meningitis — Encephalitis  (Cerebritis) — Insolution  (Sunstroke;  Heat 
Prostration;  Thermic  Fever) — Thrombosis  of  the  Cranial  Sinuses — Tumors 
of  the  Brain — Abscess  of  the  Brain — Hydrocephalus  ( Hydrops  Cerebri ; 
Water  on  the  Brain) — Infantile  Cerebral  Palsies  (Spastic  Hemiplegia; 
Diplegia;  Paraplegia) — Progressive  Bulbar  Paralysis  (Labioglossolaryngeal 
Paralysis) — Idiocy  (Imbecility  and  Feeble-mindedness) — Mongolian  Imbecil- 
ity— Amaurotic  Family  Idiocy —  aretic  Dementia — Insanity — Transverse 
Myelitis — Acute  Anterior  Poliomyelitis  ( Infantile  Spinal  Paralysis )  — Tumors 
of  the  Spinal  Cord — Syringomyelia  (Myelosyringosis) — Hereditary  Spinal 
Ataxia  (Friedreich's  Disease) — Landry's  Paralysis  (Acute  Ascending 
Paralysis) — Hereditary  Spastic  Paralysis  (Cerebrospinal  Paralysis — Loco- 
motor Ataxia  (Tabes  Dorsalis) — Multiple  Sclerosis  (Disseminated  Sclero- 
sis; Insular  Sclerosis) — Progressive  Muscular  Atrophy  (Hand  Type  of  Aran 
and  Duchenne )  ;  Leg  Type  of  Charcot-Marie-Tooth  ( Peroneal  Form )  ; 
Muscular  Atrophy  with  Pseudohypertrophy;  Juvenile  Form  (Erb's  Type)  ; 
Facioscapulohumeral    (Landouzy-Dejerine  Type) — Multiple  Neuritis 394 

CHAPTER    XII 

DISEASES    OF   THE   GLANDS,   BLOOD,   BONES,    AND   JOINTS 

Lymphatism — Simple  Acute  Adenitis — Chronic  Adenitis — Hodgkin's  Disease 
(Pseudoleukaemia;  Lymphatic  Anaemia;  Adenia;  Lymphadenoma) — Dis- 
orders of  the  Spleen — Disorders  of  the  Adrenals — Disorders  of  the  Thymus 
— Disorders  of  the  Thyroid — Cretinism — Exophthalmic  Goitre  (Graves's 
Disease;  Basedow's  Disease) — Anaemia — Chlorosis — Pernicious  Anaemia — 
Leukaemia — Haemophilia — Purpura — Spinal  Caries  (Pott's  Disease;  Spon- 
dylitis)— Hip  Disease  (Morbus  Coxarius)  ;  Coxitis — Knee- Joint  Disease 
(White  Swelling) — Dactylitis  (Chronic  Osteomyelitis;  Spina  Ventosa ; 
Spina  Pedarthrocace) — Chronic  Polyarthritis,  with  Splenic  and  Glandular 
Enlargement — Acute  Epiphysitis — Chronic  Osteoperiostitis — Acute  Osteo- 
myelitis— Osteochondritis — Arthritis    Deformans     47f> 

CHAPTER    XIII 

» 

DISEASES    OF    THE    EYE    AND    EAR 

Affections  of  the  Lids:  Blepharitis — Hordeolum,  or  Stye — Chalazion — Trichi- 
asis—  Distichiasis  —  Entropion  —  Ectropion  —  Ptosis.  Injuries  of  the  Eye- 
lids:   Ecchymosis  —  Insect-bites  —  Burns — Blepharospasm — Conjunctivitis — 


xii  CONTENTS 

PAGE 

Trachoma — Interstitial  Keratitis — Iritis — Cataract — Refraction  of  the  Eye 
— Paralysis  —  Strabismus  —  Nystagmus  —  Exophthalmos.  Diseases  of  the 
Ear :    Importance  of  Otitis  Media — Ear  Tumors — Internal  Ear   523 

CHAPTER    XIV 

THE    SPECIFIC   INFECTIOUS   DISEASES 

Exanthemata  —  Scarlet  Fever  (Scarlatina)  — Measles  (Rubeola  Morbilli)  — 
Atypical  Measles  (Complications  and  Sequelae)- — Rubella  (Rotheln,  German 
Measles) — Variola  (Smallpox) — Vaccinia  (Cow-pox) — Varioloid  (Modified 
Smallpox) — Varicella  (Chicken-pox) — Tubulated  Differentiation  of  Exan- 
themata       540 

CHAPTER  XV 

THE    SPECIFIC    INFECTIOUS    DISEASES — CONTINUED 

Pertussis  (Whooping- Cough;  Tussis  Convulsiva) — Influenza  (La  Grippe;  Ca- 
tarrhal   Fever) — Epidemic    Parotitis     (Mumps) — Diphtheria — Diphtheroid 

(Pseudodiphtheria) — Intubation  of  the  Larynx — Typhoid  Fever  (Enteric 
Fever) — Peculiarities   of   the   Infantile   Form   of   Typhoid    Fever — Malaria 

(Intermittent  Fever;  Paludism)  — Hereditary  Syphilis — Tuberculosis  — 
Glandular  Tuberculosis — Abdominal  Tuberculosis — Peritoneal  Tuberculosis 
— General  Treatment  for  Tuberculosis   560 

CHAPTER    XVI 

DISEASES    OF   THE    SKIN 

Prevalence  in  Childhood — Erythema  Simplex  (Redness  of  Skin) — Seborrhcea — 
Eczema — Miliaria — Urticaria  (Nettle-Rash;  Hives) — Impetigo  Contagiosa 
— Herpes  —  Tinea  Trichophytina  (Ringworm) — Favus  (Tinea  Favosa; 
Crusted  Ringworm;  Honeycombed  Ringworm) — Scabies  (Itch) — Pediculo- 
sis— Furunculosis —  Psoriasis — Ichthyosis —  Scleroderma  ( Dermatosclerosis ; 
Cutis  Tensa  Chronica )  — Verruca   ( Warts )  — (Edemata 603 

CHAPTER    XVII 

GENEKAL   DISEASES 

Diabetes    Mellitus — Diabetes    Insipidus — Rheumatism 624 

APPENDIX 

SICK-ROOM    HYGIENE 

Contagioxis  Diseases — Therapeutic  Suggestions — Massage — Lumbar  Puncture — 
Hydrotherapy— Hot  Pack— Cold  Pack— Sponge  Bath— Tub  Bath— Hot  Mus- 
tard Bath — Vapor  Bath — Bran  Bath — Shower  Bath — Internal  Use  of  Water 
— Nasal  Irrigation — Lavage — Gavage — Irrigation  of  the  Vagina — Enema — 
Colonic  Flushing.  Dietary:  Barley- Water  or  Gruel — Rice- Water — Egg- 
Water— Clam-Broth— Chicken-Broth— Beef-Broth— Mutton-Broth— Oyster- 
Broth — Scraped  or  Pulped  Raw  Meat — Raw-Meat  Juice — Whey — Junket 
(Sweet  Curd  for  Older  Children) — Egg- Junket — Lime- Water — Cream-of- 
Tartar   Lemonade    632 

FORMULARY 

Disinfecting  Solutions — Mouth-Wash  and  Spray — Astringents — A  Gargle  to  pre- 
pare the  Throat  for  Tonsillotomy — Anodyne  Sprays  used  in  Tubercular 
Laryngitis — Infant  Correctives — For  Relief  of  Asthma — Rubefacients 644 


Illustrations 


FIGS.  PAGE 

1.  New-born — side,  reclining  (plate )  18 

2.  New-born — front,  reclining  (plate) 18 

3.  New-born  -  back  (plate) 18 

4.  New-born — fists  doubled  (plate ) ". 1 !' 

5.  New-born — front,  sitting  (plate) 19 

6.  New-born — side,  sitting  (plate) 19 

7.  Pericranial  hemorrhage  in  new-born 19 

8  to  13.  Skull  of  new-born  (plate) * 20 

14.  Anencepbalus 21 

15.  Branchial  clefts 22 

16.  Skeletons  of  new-born   (plate) 2t 

17.  Skiagram  of  new-born   (plate) 25 

18.  Skiagram  of  new-born   (plate) 25 

19.  Lower  end  of  femur,  showing  centres  of  ossification 26 

20.  Spina   bifida    ( dissection )   27 

21.  Lungs,  heart,  thymus  and  thyroid  of  still-born  infant .  >^0 

22.  Fetal   circulation 31 

23.  Stomachs  of  new-born  ( plate ) 34 

24.  Folds  of  infant  rectum 36 

25.  Liver  in  the  new-born   37 

26.  Spleen  with  a  supernumerary  and  pancreas 38 

27.  Lobulated  kidney  of  the  new-born    38 

28.  Mesial  section  of  four  months  infant,  showing  distended  bladder 39 

29.  Genito-urinary  organs  at  birth    (plate) 40 

30.  Weight    chart .43 

31.  Weight    chart 43 

32.  Linea  albicantes   after   typhoid 44 

33.  Boas  table 45 

34.  Coronal  section  of  head  through  the  auditory  meati 47 

35.  Coronal  section  of  head  through  the  orbits 43 

36.  Vertical  mesial  section  of  head  and  trunk   (plate) 48 

37.  Dissection  showing  teeth  at  sixth  year 50 

38.  Inferior  maxillae  (plate) 50 

39.  Horizontal  section  at  third  dorsal  vertebra  (plate) 51 

40.  Horizontal  section  at  clavicle  (plate) 52 

41.  Von  Starch's  types  of  cardiac  dulness 53 

42.  Horizontal  section  at  the  eleventh  vertebra 57 

43.  Mesial  section  of  pelvis  at  fifteen  months 58 

44.  Infant's  garments    (plate) , 58 

45.  Infant's  garments    (plate) 59 

46.  Infant's   outer   garments 65 

47.  Infant's   undergarments 66 

48.  Rubber  bath-tub 79 

xiii 


xiv  ILLUSTRATIONS 

FIGS.  PAGE 

49.  Bath  thermometer 79 

50.  Scales 80 

51.  Correct  position  for  nursing 88 

52.  Holt's  creamometer 101 

53.  Feser's    lactoscope    101 

54.  Marchand's  tube       101 

55.  Babcock  test  tube 102 

56.  Babcock    centrifuge 102 

57.  Leffman  and  Beam's  test  bottle 103 

58.  Office  centrifuge 103 

59.  Lactometer 104 

60.  Freeman's    pasteurizer 116 

61.  Arnold's  sterilizer 117 

62.  Ladd's  table  for  milk  modification 119 

63.  Ladd's  table  for  milk  modification 119 

64.  Gurler's  table  for  milk  modification 120 

65.  Westcott's  chart  for  milk  modification 122 

66.  Materna 122 

67.  Chapin's  milk   dipper    122 

68.  Connor's  table  for  milk  modification 123 

69.  Position  for  bottle  feeding 125 

70.  Nasal    syringe 133 

71.  Oil  atomizer 133 

72.  Foot  and  orthopaedic  shoe 134 

73.  Foot  and  orthopaedic  shoe 135 

74.  Skiagram  of  lower  extremities  (plate) 134 

75.  Skiagram  showing  effects  of  large,  wadded  diaper  (plate) 135 

76.  Pelvis  at  birth,  showing  cartilage 136 

77.  Skiagram  showing  pelvis  constricted  by  tight  diaper  (plate) 136 

78.  Skiagram  showing  effect  of  tight  bands  on  thorax  (plate) 136 

79.  Saddle-shaped    palate ; 138 

80.  Krohn's  diagram  of  fatigue  periods  142 

81.  Premature    infant 146 

82.  Incubator 147 

83.  Feeding  tube    148 

84.  Anencephalus     150 

85.  Spina  bifida 153 

86.  Amputations  of  extremities  in  utero 155 

87.  Congenital  dislocation  of  hips,  front  view 155 

88.  Skiagram  of  intra  uterine  malformations  of  fingers 156 

89.  Congenital  dislocation  of  hips  and  back   (plate) 158 

90.  Congenital  dislocation  of  hip  (dissection)    (plate)  158 

91.  Congenital  talipes  (plate) 158 

92.  Double  cleft  palate,  front  view  (plate) : 159 

93.  Single  cleft  palate,  side  view  (plate) 159 

94.  Cleft  palate,  front  view  (plate) 159 

95.  Cleft  palate,  after  operation   (plate) 159 

96.  Meckel's  diverticulum 159 

97.  Atresia  ani  (plate) 160 

98.  Atresia  recti  (plate)   160 


ILLUSTKATIONS  xv 

FIGS.  PAGE 

99.  Atresia  of  both  anus  and  rectum   (plate)  160 

100.  Common  cloaca  (plate) 160 

101.  Congenital  dilated  stomach   (plate)  161 

102.  Congenital  exompholos  (plate)  161 

103.  Exstrophy  of  bladder 162 

104.  Achondroplasia,  front  view  (plate) 164 

105.  Achondroplasia,  side  view  (plate) 164 

106.  Achondroplasia,  back  view   (plate)  164 

107.  Achondroplasia,  dissection  (plate) 165 

108.  Skiagram  of  femur  of  achondroplasic  (plate) 165 

109.  Examination  of  chest 167 

110.  Infantile    atrophy 184 

111.  Fetal  rickets 187 

112.  Rhachitic    femur 187 

113.  Rhachitic  curvature  of  spine 189 

114.  Rhachitic    curvature    of    spine 189 

115.  Rhachitic    deformity 190 

110.  Rhachitic   family 190 

117.  Rhachitic    deformity 191 

118.  Rhachitis 191 

119.  Skiagram  of   genu  valgum 192 

120.  Skiagram  of  genu  varum 192 

121.  Rhachitic  deformities 194 

122.  Same  after  correction    194 

123.  Rhachitic    bow-legs    195 

124.  Same  after  correction 195 

125.  Rhachitic  knock-knees 196 

126.  Same  after  correction 196 

127.  Adenoid    facies 225 

128.  Mouth   breather    225 

129.  High-arched   palate 226 

130.  Digital  exploration  for  adenoids 227 

131.  Effects  of  thumb  sucking 228 

132.  Characteristic  attitude  in  retropharyngeal  abscess 231 

133.  Skiagram  of  foreign  body  in  oesophagus   (plate) 232 

134.  Emaciation  due  to  stricture  of  oesophagus 234 

135.  Stricture  of  oesophagus 235 

136.  Ulceration  of  Peyer's  patch    (plate) 252 

137.  Intussusception    273 

138.  Palpating  the  appendix 276 

139.  Direction  of  anal  outlet 279 

140.  Malformation  at  aortic  orifice 289 

141.  Congenital  malformation  of  heart 290 

142.  Congenital  malformation  of  heart 291 

143.  Chronic  valvular  heart   disease 300 

144.  Nasal  irrigation 314 

145.  Diphtheritic  membrane  from  trachea  and  bronchi   (plate) 322 

146.  Exploratory  aspiration  of  chest 362 

147.  Rudimentary  kidney 37_° 

148.  Cystic  tumors  of  kidney   3/ 1 


xvi  ILLUSTRATIONS 

FIGS.  PAGE 

149.  Tetany 401 

150.  Chorea   •'. 409 

150a.  Athetosis     413 

152.  Gun-hamrner  position 424 

153.  Meningitis    424 

154.  General    purpuric    eruption.      Death    on    the    12th.    day    of    continuous 

convulsions 427 

154a.  Hydrocephalus 443 

155.  Congenital  enlargement  of  thyroid  gland 443 

156.  Brain  hemorrhage  after   forceps 448 

157.  Birth  palsy.    Microcephalic  idiot 449 

158.  Cerebral  palsy 449 

159.  Prenatal  cerebral  palsy.     Diplegic  idiot • 450 

160.  Spastic  contracture 451 

161.  Diplegia 452 

162.  Section  of  medulla  in  bulbar  paralysis 454 

163.  Progressive  bulbar  paralysis   454 

164.  Mongolian  imbecility  (plate) 458 

165.  Mongolian  imbecility,  profile  (plate)   459 

166.  Tongue  in  Mongolian  imbecility  (plate) 459 

167.  Mongolian  imbecility   (plate) ■ 459 

168.  Slight  degree  of  Mongolianism   (plate) 459 

169.  Amaurotic  family  idiocy,  before  development  of  symptoms 459 

170.  Amaurotic  family  idiocy 460 

171.  Eyeground  in  amaurotic  family  idiocy  (colored  plate) 460 

172.  Amaurotic  family  idiocy 461 

173.  Amaurotic  family  idiocy  .  -. 461 

174.  Amaurotic  family  iodicy,  convulsions  in 462 

175.  Cupped    foot 472 

176.  Pseudohypertrophic  paralysis 477 

177.  Progressive  muscular   dystrophy 477 

178   to    185.  Pseudohypertrophic   muscular   paralysis,   eight   characteristic   pos- 
tures assumed  in  rising  from  the  floor   (plates) 478 

186.  Acute  cervical  adenitis 483 

187.  Hodgkin's    disease •  •  •   4S6 

188.  Hodgkin's  disease  with  enlarged  liver  and  spleen 487 

189.  Palpating  the   spleen 4SS 

190.  Splenic    anaemia 489 

191.  Cretin,  untreated 493 

192.  Cretin,  untreated 494 

193.  Cretin,  after  treatment, 495 

194.  Cretin,  after  treatment  (plate) 506 

195.  Cretin,  before  treatment  (plate) 506 

196.  Cretin,  after  treatment  (plate) 506 

197.  Post-diphtheritic   purpura 508 

198.  Peliosis  rheumatica 509 

199.  Spinal  caries,    (dissection)   512 

200.  Spinal  caries,  psoas  abscess 512 

201.  Dorsal  caries,  infrascapular  abscess 513 

202.  Spinal  caries,  psoas  abscess 513 


ILLUSTRATIONS  xvii 

FIGS.  PAGE 

203.  Characteristic  posture  of  spinal  caries 514 

204.  Hip  disease 516 

205.  Tuberculous  knee  and  elbow 517 

20G.  Tuberculous  sinuses  of  ankle 519 

207.  Tuberculous    dactylitis 519 

208.  Koplik's  spots    ( colored  plate ) 550 

208a.  Chicken-pox     558 

209.  Conjunctival  ecchymosis  in  pertussis    562 

210.  Mumps     5G7 

212.  Rupture  of  tuberculous  gland  in  trachea . 593 

213.  Rupture  of  tuberculous  gland  in  oesophagus 594 

214.  Pulmonary  tuberculosis  with  large  liver 597 

215.  Mesenteric  and  pulmonary  tuberculosis ° 600 

216.  Tuberculous  peritonitis  with  ascites 601 

217.  Tuberculous  peitonitis  with  ascites,  side  view 601 

218.  Lumbar    puncture 637 

219.  Nasal  feeding 640 

220.  Colonic  flushing •  • 642 


PART    I 

Anatomy,  Physiology,  and  Hygiene 
of  the  Developing  Period 

CHAPTER   I 
ANATOMY    OF    THE    NEW-BORN 

THE    SKIN 

The  infant 's  integument  at  birth  is  usually  more  or  less  covered  with 
a  thick  whitish  substance,  the  vernix  caseosa,  which  is  most  abundant  in 
the  flexures  and  depressions,  and  upon  the  scalp.  It  consists  of  a  mixture 
of  cast-off  epithelium,  lanugo,  and  the  product  of  the  sebaceous  glands. 

Usually  upon  delivery  the  color  is  dusky  blue,  owing  to  venous  stasis 
from  the  long  pressure.  After  a  few  full  inspirations  this  color  changes 
to  the  "  boiled  lobster"  hue.  About  the  third  day  exfoliation  begins 
and  continues  for  a  week  or  ten  days.  During  this  time  the  hyperemia 
is  marked ;  this  gradually  subsiding,  the  skin  assumes  an  icteroid  tint. 

The  texture  of  the  skin  is  very  delicate,  and  the  downy  growth, 
lanugo,  which  was  more  abundant  in  the  sixth  and  seventh  months  of 
intrauterine  life,  still  covers  the  body. 

The  margin  of  the  nails  projects  far  over  the  ball  of  the  fingers.  It 
was  formed  at  an  early  period  and  is  much  thinner  than  the  part  resting 
on  the  bed  of  the  nail.  This  margin  breaks  readily  and  becomes  detached 
soon  after  birth. 

At  first  view  the  large  head,  small  chest,  enormous  abdomen,  and 
insignificant  extremities  of  a  new-born  infant  seem  out  of  all  proportion 
(Figs.  1  to  6).  Not  until  the  student  has  gained  a  knowledge  of  develop- 
ment and  growth  up  to  this  period  can  he  adjust  his  ideas  to  accept  these 
as  normal. 

Upon  comparing  the  records  of  many  hospitals  in  this  and  other 
countries,  the  average  weight  at  birth  for  boys  is  found  to  be  32S0 
grammes  and  for  girls  3130  grammes  (about  seven  and  one-fifth  and 
seven  pounds).  The  average  length  is  forty-six  to  fifty  centimetres 
(eighteen  to  twenty  inches). 

Many  observations  have  shown  a  constant  proportional  relationship 
between  the  different  members  of  the  normal  infant  at  birth.  Any 
marked  variation  in  these  proportions  is  considered  an  abnormality  of 

2 


18  ANATOMY    OF    THE    NEW-BORN 

development.  The  following  simple  rule  will  aid  the  student  in  remem- 
bering this  relationship.  The  circumference  of  the  thorax  in  centimetres 
should  equal  one-half  of  the  length  plus  ten.  If  estimated  in  inches,  add 
four  to  half  the  length.  The  circumference  of  the  head  should  equal  that 
of  the  thorax  plus  two.  The  abdomen  is  usually  one  to  two  centimetres 
larger  in  circumference  than  the  head,  for  example : 

Centimetres.  Inches. 

Length     46  18 

Circumference  of  thorax    33  13 

Circumference  of  head      35  »  13f 

Circumference  of  abdomen     36  14£ 

From  the  abundant  deposition  of  subcutaneous  fat,  the  contour  of  the 
body  and  limbs  is  well  rounded,  the  location  of  the  articulations  being 
marked  by  dimples.  A  marking  never  absent  from  a  normal,  plump 
infant  after  the  first  month  is  a  deep  sulcus  extending  around  the  inner 
aspect  of  the  thigh. 

Recent  investigators  have  questioned  the  correctness  of  the  statement 
that  the  bones  of  infants  .contain  more  animal  matter  than  do  those  of 
adults, — viz.,  one-third.  Their  analyses  go  to  prove  that  equal  weights 
of  bone  contain,  at  all  ages,  and  in  all  bones,  nearly  the  same  relative 
proportions  of  animal  and  earthy  matter.  A  particle  of  bone  is  a  definite, 
not  a  variable  compound.  Hardness  and  compactness  depend  upon  the 
quantity  of  bone  condensed  in  a  given  space.  The  softness  and  elasticity 
of  the  bones  of  infancy  are  due  to  their  vascularity,  the  sponginess  of 
their  texture,  and  to  the  layers  of  cartilage  and  membrane  not  yet 
ossified.  Equal  weights  of  corresponding  sections  of  adult  and  infant 
bones  would  certainly  yield  different  percentages  of  earthy  and  animal 
matter.  The  error  lies  in  regarding  the  sections  as  containing  equal 
amounts  of  bone.  A  peculiarity  of  infant  bones  is  seen  in  the  composi- 
tion of  the  red  marrow  which  is  found  in  all  the  long  bones.  It  consists 
of  seventy-five  per  cent,  water,  the  twenty-five  per  cent,  solids  containing 
only  one  per  cent,  fat,  while  the  yellow  marrow  of  adult  bones  contains 
ninety-six  per  cent.  fat. 

The  centres  of  ossification  do  not  all  appear  at  once,  some  not  until 
after  birth,  but  all  in  regular  succession  and  at  stated  periods.  The  early 
ossification  corresponds  directly  with  the  functional  importance  of  the 
particular  bone, — e.g.,  that  of  the  lower  jaw  and  ribs,  which  renders 
possible  respiration  and  suction  from  birth. 

THE   SKULL. 

The  head,  being  plastic,  shows  the  pressure  effects  of  recent  parturi- 
tion, sometimes  presenting  a  great  elongation.  Not  infrequently  the 
contour  is  still  further  modified  by  the  caput  succedaneum.  By  the  end 
of  the  first  week  the  head  has  resumed  its  normal  shape. 

The  integument  covering  the  head  is  thicker  than  that  of  any  other 
part  of  the  body  and  is  closely  adherent  to  the  aponeurosis  of  the  occipito- 


Fig.  4. 


Fig.  5. 


Infant  at  birth. 


Fig.  6. 


THE    SKULL 


19 


frontalis  muscle.  The  extreme  mobility  of  the  scalp  in  infancy  is  due  to 
the  loose  attachment  of  the  above-mentioned  tissues  to  the  pericranium, — 
points  to  be  remembered  in  considering  extravasations  in  this  region 
(Fig.  7).  The  pericranium  may  be  regarded  as  the  remains  of  the 
outer  layer  of  the  developing  membrane  which  surrounded  the  bones  in 
fetal  life.  It  is  very  slightly  attached,  except  at  the  sutures  where  it 
blends  with  the  dura  mater. 

The  skull  at  birth  presents  marked  peculiarities  not  only  in  its 
entirety,  but  also  as  to  its  individual  bones,  and  further  in  the  per- 
sistence of  some  of  its  chondral  portions. 

Considered  as  a  whole  the  large  size  of  the  head  compared  with  that 
of  the  body,  and  the  predominance  of  cranial  over  facial  proportions, 
are  marked  features ;  the  proportion  of  face  to  cranium  has  been  put  as 


Fig.  7.— Pericranial  hemorrhage  in  new-born.    (Dr.  P.  Bassoe.) 

1 :  8  (Figs.  5,  6,  8),  while  in  later  life  it  is  as  1 :  2.  The  parietal  eminences 
are  large  and  conspicuous.  Adjacent  margins  of  the  bones  of  the  vault 
are  separated  by  fibrous  tissue  continuous  with  the  dura  mater  internally 
and  the  pericranium  externally.  The  bones  of  the  vault  consist  of  a 
single  layer  without  diploe.  At  the  angles  of  the  parietal  bones  are 
membranous  spaces,  called  fontanelles.  The  largest  and  most  important 
of  these  is  the  anterior  median,  which  is  situated  at  the  junction  of  the 
frontal,  sagittal,  and  coronal  sutures  (Fig.  9).  It  is  quadrilateral, 
from  two  to  four  centimetres  long  and  one  to  two  centimetres  wide,  and 
immediately  after  birth  it  is  slightly  depressed.  In  this  space  there  is  a 
regular  pulsation  corresponding  in  frequency  with  the  action  of  the 
heart.  The  posterior  median  fontanelle  is  smaller  and  triangular  in 
shape.     The  remaining  four  lateral  spaces  are  found  at  the  inferior 


20  ANATOMY    OF    THE    NEW-BORN 

angles  of  the  parietal  bones  and  are  irregular  in  outline  (Figs.  10  to  12). 
Supernumerary  (AA'ormianj  bones  are  frequently  found  in  the  line  of 
sutures  or  at  the  fontanelles. 

At  the  base  of  the  skull  the  most  striking  points  are,  first,  the  absence 
of  the  mastoid  processes,  and,  second,  the  large  angle  which  the  pterygoid 
plates  form  with  the  skull  base.  (In  the  adult  the  angle  is  almost  a 
right  one.  j  The  base  is  relatively  short,  and  the  lower  border  of  the 
mental  symphysis  is  on  a  level  with  the  occipital  condyles.  The  facial 
skeleton  is  relatively  small  in  consequence  of  the  small  size  of  the  nasal 
fossa;  and  the  undeveloped  condition  of  both  jaws  (Fig.  13).  The  ex- 
ternal auditory  meatus  is  found  anterior  to.  the  middle  of  a  straight  line 
connecting  the  symphysis  mentis  and  the  occipital  condyle.  In  the  adult 
it  is  decidedly  posterior  to  the  centre  of  this  line.  Embryology  shows 
that  the  vault  of  the  skull  is  formed  in  membrane  and  the  base  in  carti- 
lage. Although  in  fetal  life  ossification  begins  first  in  the  vault,  at  birth 
it  is  always  more  advanced  at  the  base.  Pathology  often  makes  this 
distinction  more  manifest.  Among  the  more  common  of  the  gross  mal- 
formations is  that  which  shows  an  entire  absence  of  all  parts  of  the 
cranium  formed  in  membrane,  while  the  base  is  more  or  less  perfectly 
developed,  as  in  the  anencephalus  (Fig.  14). 

The  occipital  bone  consists  of  four  distinct  plates:  the  squamo-,  the 
basi-,  and  two  ex-occipitals  united  by  strips  of  cartilage.  The  first 
named  portion,  which  is  formed  in  membrane  and  belongs  to  the  vault, 
is  often  separated  from  the  ex-occipitals  by  a  wide  fissure  (Fig.  11). 
These  fissures  are  of  interest  for  they  have  been  mistaken  for  fractures. 
The  fact  is,  it  is  difficult  to  fracture  the  skull  of  a  young  infant,  as  the 
bones  are  soft  and  yielding  and  a  blow  indents  without  fracturing. 
Another  membranous  space  extends  from  the  squamo-occipital  portion  to 
the  foramen  magnum.  It  is  here  that  a  hernia  of  the  membranes  or  brain 
occurs.  There  is  no  jugular  process  and  the  grooves  of  the  lateral 
sinuses  are  absent  or  but  rudimentary. 

The  sphenoid  consists  of  three  pieces,  the  median,  containing  the  basi- 
sphenoid,  and  the  two  lateral,  which  are  made  up  of  the  greater  wings 
and  internal  pterygoid  plates.  The  dorsum  ephippii  is  cartilaginous; 
there  are  no  air-sinuses  and  the  optic  foramina  are  large  and  triangular 
(Fig.  13;. 

The  temporal  is  also  made  up  of  parts  which  are  easily  separable, — 
viz.,  squamous,  petrosal,  and  mastoid.  The  mastoid  process  is  not  devel- 
oped, and  the  jugular  fossa  is  only  a  shallow  depression. 

The  antrum  is  relatively  large  and  resembles  the  tympanic  cavity  in 
having  a  very  thin  roof  separating  it  from  the  cranial  cavity,  but  it 
approaches  much  nearer  the  outer  surface  of  the  skull  than  does  the  tym- 
panum. The  mastoid  cells  are  not  j>resent  at  birth,  and  it  is  of  interest 
in  this  connection  to  know  that  they  are  not  present  in  twenty  per  cent, 
of  adult  mastoids.  The  petrosal  is  of  loose  and  open  texture,  resembling 
un glazed  porcelain,  thus  offering  a  striking  contrast  to  the  dense  and 
ivory-like  petrosal  of  adult  life. 


Fig.  8.— Skull  of  new-born.    Frontal  bone  depressed  by  desiccation.    (Dr.  J.  D.  Merrill.) 


Fig  9— Skull  at  birth.     Vertex.     (Dr.  J.  D.  Merrill  ) 


Fig.  10. — Skull  at  birth,  showing  tympanic  membrane  and  notch  of  Revinus. 


Fig.  11.— Skull  at  birth.    Base.     (Dr.  J.  D.  Merrill.) 


Fig.  12.— Skull  at  birth.    Base.    Teeth  exposed  by  dissection.    (Dr.  J.  D.  Merrill.) 


Fig.  13.— Skull  at  birth.    Front.     (Dr.  J.  D.  Merrill.) 


THE    EAR  21 

The  ear  at  birth  presents  some  interesting  conditions,  for  growth  has 
been  by  no  means  uniform,  and  some  parts  are  of  full  adult  size  and 
form,  while  others  do  not  attain  full  development  until  after  puberty. 
To  the  first  class  belong  the  internal  ear  and  tympanic  cavity  with  its 
ossicles  and  the  mastoid  antrum ;  in  the  second  class  are  found  the  ex- 
ternal auditory  meatus,  Eustachian  tube,  and  the  mastoid  process.  The 
external  meatus  is  extremely  short  on  account  of  the  non-development  of 
its  bony  portion,  which  is  now  represented  by  a  mere  ring  (Fig.  10).  It 
consists  of  an  external  part  which  is  cartilaginous  and  an  internal  part 
which  is  osseo-fibrous.  The  canal  passes  inward  with  a  decided  downward 
inclination,  so  that  the  floor  of  the  meatus  lies  nearly  parallel  with  the 
outer  surface  of  the  membrane.  The  latter  was  formerly  described  as 
being  more  nearly  horizontal  than  in  the  adult,  but  more  recent  investi- 


Fig.  14.— Anencephalus.     (Rush  Medical  Museum.) 

gation  has  proved  that  there  is  no  perceptible  difference  between  the 
inclination  of  the  membrane  of  the  new-born  and  that  of  maturity.  The 
cavity  of  the  middle  ear  is  of  about  adult  size,  but  there  is  one  peculiarity 
in  connection  with  the  roof  in  the  infant  which  is  worthy  of  notice, — 
viz.,  the  existence  of  a  petro-squamous  suture.  While  it  exists,  it  facili- 
tates the  extension  of  infections  from  the  mucous  membrane  of  the 
tympanum  to  the  dura  mater.  The  mucous  membrane  is  described  as 
being  in  a  swollen  condition.  To  this  and  to  the  absence  of  air  is 
ascribed  the  deafness  of  the  first  hours  of  extra-uterine  life.  Generally 
there  is  a  deficiency  in  the  upper  part  of  the  groove  to  which  the  tym- 
panic membrane  is  attached,  the  notch  of  Bivinus,  which  is  merely 
covered  by  the  skin  lining  the  meatus.  At  this  unprotected  area  may 
occur  the  escape  of  fluid  from  the  middle  ear  without  perforation  of 
the  membrane.  The  membrana  tympani  is  less  securely  attached  at  this 
notch  than  at  the  rest  of  its  circumference ;  therefore,  when  subjected  to 
violent  concussion  it  is  liable  to  give  way  at  this  point. 


22  ANATOMY    OF    THE    NEW-BORN 

The  Eustachian  tube  differs  from  that  of  the  adult  in  its  length, 
the  size  of  its  lumen,  its  direction,  and  in  the  condition  of  its  walls. 
The  length  is  from-  seventeen  to  eighteen  millimetres — about  half  that 
of  the  adult.  The  tympanic  orifice  is  as  large  in  the  infant,  but  the 
pharyngeal  opening  is  much  smaller.  The  growth  of  the  tube  occurs 
mainly  in  the  anterior  portion  and  is  associated  with  a  projection  of  the 
posterior  lip  of  the  pharyngeal  orifice  on  the  lateral  wall  of  the  pharynx. 
The  tube  is  nearly  horizontal,  forming  an  angle  with  the  horizon  of  not 
more  than  ten  degrees,  while  in  the  adult  the  inclination  is  about  forty- 
five  degrees.  There  is  scarcely  any  osseous  Eustachian  tube,  six-tenths 
of  it  being  cartilaginous. 

In  the  parietal  bones,  the  eminences,  which  indicate  the  spots  in  which 
ossification  commences,  are  large  and  conspicuous.     The  grooves  for  the 


Fig.  15.— Branchial  clefts.    (Gray.) 

blood-sinuses  are  absent  or  but  slightly  marked,  as  is  the  case  in  the 
other  cranial  bones. 

The  frontal  consists  of  two  bones  separated  by  a  median  (metopic) 
suture  (Fig.  13).  The  superciliary  ridges  and  frontal  sinuses  are  want- 
ing. The  nasal  spine  is  absent  and  the  orbital  plates  are  often  incomplete. 
There  is  no  temporal  ridge. 

The  ethmoid  is  made  up  of  two  scroll-like  bones,  very  delicate 
and  covered  with  depressions  which  give  it  a  worm-eaten  appearance. 
The  ethmoid  cells  do  not  appear  before  the  third  year.  It  may  be 
noted  here  that  a  constant  communication  exists  between  the  nasal 
veins  and  the  superior  longitudinal  sinus  through  the  foramen  cascum. 
This  connection  may,  in  part,  serve  to  explain  the  occurrence  of  intra- 
cranial mischief  as  a  consequence  of  inflammatory  affections  of  the  nasal 
cavity. 

When  the  mouth  is  formed  in  the  foetus  (Fig.  15),  there  is  at  first 
no  separation  between  it  and  the  nose ;  but  the  general  cavity  is 
gradually  closed  in  by  the  horizontal  plates  of  the  superior  maxil- 
lary and  palate  bones  advancing  towards  each  other,  and  the  septum 


THE    FACE  23 

of  the  nose  descending  from  above  to  join  them  in  the  middle  line.  Nor- 
mally the  only  trace  of  the  original  fissure  is  the  nasopalatine  canal 
(Fig.  12). 

At  birth  a  peculiarity  of  the  palate  bones  is  the  equal  length  of  the 
vertical  and  horizontal  plates. 

The  inferior  maxillary  is  represented  by  two  nearly  horizontal 
troughs  of  bone  lodging  the  unerupted  teeth.  Each  half  is  joined  at  the 
symphysis  by  fibrous  tissue  (Fig.  12).  The  gums,  composed  of  dense, 
fibrous  tissue,  form  a  tough  protecting  covering  to  the  developing  teeth. 
The  margins  of  the  superior  and  inferior  maxilla?  do  not  approximate 
at  birth.  The  alveolar  arch  in  the  new-born  describes  almost  the  segment 
of  a  circle ;  in  the  adult  it  is  semi-elliptical. 

At  birth,  remnants  of  the  primitive  chondral  skull  are  abundant. 
Cartilaginous  tracts  exist  between  the  various  portions  of  the  occipital 
and  also  at  the  lines  of  junction  of  adjacent  bones.  The  dorsum  ephippii 
is  entirely  cartilaginous,  as  are  the  styloid  processes  and  a  large  portion 
of  the  hyoid. 

THE    FACE. 

The  rotundity  of  the  face  is  due  to  the  generous  deposit  of  sub- 
cutaneous fat,  especially  over  the  cheeks.  Over  the  buccinator  muscles, 
in  addition  to  the  ordinary  subcutaneous  layer  of  fat,  there  is  an  arrange- 
ment of  fatty  lobules  surrounded  by  a  capsule  on  either  side.  They  have 
been  called  "sucking  cushions,"  because  they  are  thought  to  prevent 
the  buccinator  muscles  being  pressed  inward  between  the  alveolar  arches 
when  a  vacuum  is  produced  in  the  mouth.  The  skin  of  the  face  is  very 
thin  and  exceedingly  vascular,  hence  it  is  often  the  seat  of  mevi.  It  is 
attached  to  the  adjacent  structures  by  loose,  cellular  tissue,  excepting 
over  the  alae  of  the  nose  and  over  the  chin  where  it  is  closely  adherent 
to  the  parts  beneath. 

By  some  writers  it  is  stated  that  the  eye  at  birth  is  anatomically  com- 
plete. However,  others  have  claimed  that  the  macula  lutea  is  not  fully 
developed,  that  the  cornea  has  not  attained  a  full  degree  of  transparency, 
and  that  the  recessus  opticus  is  more  marked,  all  of  which  would  preclude 
the  possibility  of  perfect  optic  function,  even  if  the  brain  were  ready  to 
receive  and  interpret  impressions.  Examinations  of  the  eyes  of  many 
new-born  infants  have  shown  them  all  to  be  hypermetropic.  The  color 
of  the  iris  is  a  bluish  gray.  The  pupils  are  large  and  sensitive  to  light. 
The  lachrymal  glands  are  not  fully  developed. 

The  tongue  contains  much  lymphoid  tissue,  a  considerable  part  of 
which  is  massed  under  the  mucous  membrane  of  the  posterior  third. 

The  arch  of  the  hard  palate  varies  in  different  individuals ;  a  high, 
narrow  arch  being  considered  a  stigma  of  degeneration. 

The  nose  is  of  relatively  small  size  and  the  respiratory  portion 
is  very  small.  The  septal  cartilage  is  usually  straight.  The  height 
of  the  posterior  nares  is  six  to  seven  millimetres,  and  the  breadth 
between  the  pterygoid  processes  at  the  hard  palate  is  nine  millimetres. 


21  ANATOMY    OF    THE    NEW-BORN 

With  these  dimensions  it  is  easy  to  see  how  congestion  would  nearly 
obliterate  the  small  passage  and  the  resulting  obstruction  be  a  source  of 
danger. 

The  pharynx  is  always  widest  near  the  hyoid  bone  and  narrowest 
opposite  the  cricoid  cartilage ;  hence  foreign  bodies  which  become  lodged 
in  the  pharynx  may  be  reached  with  the  finger.  The  connective  tissue 
between  the  pharynx  and  the  spine  is  very  lax,  allowing  large  accumu- 
lations of  pus,  as  in  post-pharyngeal  abscess  and  cervical  necrosis.  The 
internal  carotid  artery  and  the  pneumogastric,  glossopharyngeal,  and 
hypoglossal  nerves  are  in  relation  to  the  walls  on  either  side,  a  point  of 
interest  from  the  symptoms  caused  by  compression  of  these  important 
structures  from  tumors  in  this  region.  The  importance  of  the  naso- 
pharynx is  due  to  the  vascularity  and  the  abundant  supply  of  lymphatic 
glands  and  vessels  in  this  region,  particularly  in  the  posterior  wall.  The 
opening  of  the  Eustachian  tube  is  at  the  level  of  the  hard  palate  at  birth. 
The  horizontal  direction  of  the  tube  and  its  unguarded  orifice  facilitates 
the  infection  of  the  middle  ear  from  the  nasopharynx. 

THE   NECK. 

The  neck  is  usually  described  as  relatively  very  short.  An  examina- 
tion of  the  skeleton  shows  the  cervical  portion  of  the  spine  is  actually 
relatively  long  (Fig.  16)  and,  on  account  of  the  slight  development  of 
the  facial  part  of  the  skull,  the  lower  jaw  occupies  a  high  position,  so 
that  the  length  is  still  more  increased.  It  is  true  the  manubrium  sterni 
is  higher  than  in  the  adult,  but  this  does  not  compensate  for  the  slight 
vertical  extent  of  the  face.  The  thick  layer  of  subcutaneous  fat  tends 
to  make  the  neck  appear  short  and  thick  (Fig.  3). 

In  the  fcetus  clefts  occur  between  the  branchial  arches,  which  are  five 
in  number  ('Fig.  15).  The  first  lays  the  foundation  for  the  lower  jaw; 
the  second,  the  incus,  styloid,  stylohyoid  ligament  and  the  lesser  cornu 
of  the  hyoid  bone.  From  the  third  are  formed  the  body  and  greater 
cornu  of  the  hyoid,  while  the  fourth  and  fifth  take  part  in  the  formation 
of  the  soft  parts  of  the  neck  below  the  hyoid. 

VERTEBRAL    COLUMN. 

In  the  new-born  infant  the  cervical  and  lumbar  regions  are  nearly 
equal  in  length,  while  in  the  adult  the  ratio  is  2 :  3.  Much  investigation 
has  been  made  concerning  the  curvature  of  the  spine  at  this  period.  In 
the  living  body  it  is  impossible,  from  the  great  flexibility  and  the  in- 
fluence of  muscular  contraction  and  gravity,  to  estimate  correctly  the 
normal  curve.  The  effects  of  gravity  in  frozen  sections  render  the 
results  by  this  method  unreliable.  Most  authorities  state  that  the  spine 
presents  two  curves  with  their  concavities  forward,  one  in  the  dorsal 
region,  and  the  other  formed  by  the  sacrococcygeal  vertebrae. 

A  peculiarity  of  the  infant  spine  is  its  extreme  flexibility.  It  is,  in 
fact,  almost  wholly  cartilaginous  at  birth,  the  centres  of  ossification  being 
present  but  the  process  only  slightly  advanced   (Fig.  17).     There  are 


\ 


A 


■ 


Figs.  17  and  18.— Skiagram  of  new-born  infant. 


LONG    BONES  25 

three  nuclei  for  each  vertebra,  one  for  the  body  and  one  for  each  lateral 
mass.  Ossification  of  the  bodies  begins  about  the  centre  of  the  column 
(ninth  dorsal)  and  extends  upwards  and  downwards;  while  ossification 
of  the  laminae  commences  above  and  proceeds  gradually  downwards. 
Arrest  of  development  of  the  lamina:  gives  rise  to  a  cleft,  spina  bifida 
(Fig.  20),  allowing  a  hernia  of  the  membranes  and  sometimes  of  fila- 
ments of  the  cord.  This  usually  occurs  in  the  lumbar  arches  and  upper 
part  of  the  sacrum.  Because  of  surgical  interest,  it  will  be  well  to  re- 
member that  the  fourth  lumbar  vertebra,  at  all  ages,  is  on  a  level  with 
the  highest  point  of  the  crest  of  the  ilium. 

LONG   BONES. 

The  clavicle  is  peculiar  not  only  in  that  it  is  the  first  bone  of  the 
skeleton  to  ossif y,  but  that  ossification  in  it  begins  in  its  primary  sub- 
stance before  the  deposition  of  cartilage.  At  birth  the  entire  shaft  is 
bony,  the  ends  only  being  cartilaginous.  This  bone  is  more  frequently 
fractured  during  delivery  than  is  any  other  (Fig.  17).  It  is  stated  that 
one-half  the  cases  of  broken  collar-bone  occur  before  the  age  of  five 
years.  This  is  explained  by  the  fact  that  the  clavicle  is  in  a  breakable 
condition  at  a  time  when  most  of  the  long  bones  still  present  much  unossi- 
fied  cartilage  in  their  parts.  That  the  periosteum  is  comparatively 
thick  and  not  closly  attached  to  the  bone  are  circumstances  that 
favor  subperiosteal  or  green-stick  fracture,  which  is  characteristic  of 
early  years. 

The  scapula  is  chiefly  osseous,  only  the  coracoid  and  acromion  proc- 
esses, a  narrow  rim  of  the  posterior  border,  and  the  tip  of  the  inferior 
angle  being  cartilaginous.  Sometimes  a  failure  of  union  between  the 
acromion  process  and  the  spine  occurs,  the  junction  being  effected  by 
fibrous  tissue.  In  some  cases  of  supposed  fracture  of  the  acromion,  with 
ligamentous  union,  it  is  probable  that  the  detached  segment  was  never 
united  to  the  rest  of  the  bone. 

It  may  be  said  of  the  shafts  of  all  the  long  bones  at  birth,  that  they 
are  mainly  cylindrical  and  free  from  ridges.  The  long  bones  afford  the 
best  example  of  the  process  of  ossification,  for  it  depends  upon  both 
membranous  and  cartilaginous  formation.  The  process  begins  in  the 
centre  of  the  shaft  (diaphysis),  and  proceeds  towards  the  extremities 
(epiphyses),  which  remain  cartilaginous  until  some  time  later,  when 
centres  of  ossification  occur  in  them  also  (Figs.  18  and  19).  The  ex- 
tremities are  separated  from  the  shaft  by  a  layer  of  epiphyseal  cartilage 
until  the  growth  of  the  bone  is  completed.  Simultaneously  with  the  ossific 
changes  in  the  centre  of  the  cartilage,  a  very  vascular  membrane  is  de- 
veloped around  the  shaft.  This  is  the  periosteum,  and  consists  of  two 
layers  which  serve  as  a  nidus  for  the  ramifications  of  vessels  which  pass 
from  it  into  the  bone.  In  infants  it  is  thick  and  vascular  and  is  con- 
nected only  at  the  epiphyseal  cartilages,  being  separated  from  the  shaft 
by  a  layer  of  soft  blastema  containing  osteoblasts,  from  which  ossifica- 
tion proceeds  on  the  surface  of  the  growing  bone.    Bones  grow  in  length 


26 


ANATOMY    OF    THE    NEW-BOEN 


chiefly  by  the  deposition  taking  place  upon  the  extremities  of  the  diaphy- 
sis  and  in  the  extension  of  the  ossific  centres  of  the  epiphyses.  They 
increase  in  circumference  by  deposition  from  the  periosteum  on  the 
external  surface,  while  the  medullary  canal  is  produced  by  absorption 
from  within. 

Owing  to  the  long  bones  having  separate  centres  of  ossification,  and 
the  interposition  of  the  layers  of  cartilage  between  them  and  the  shaft 
until  its  full  length  is  attained,  the  bone  is  indurated  in  the  parts  where 
the  greatest  strength  is  required,  while  the  longitudinal  growth  is  facili- 
tated. About  the  centre  of  the  shaft  there  is  a  large  foramen  leading 
obliquely  into  the  medullary  canal ;  through  this  passes  the  medullary 
artery,  usually  a  branch  of  the  main  artery  of  the  part  of  the  limb  to 
which  the  bone  belongs. 

The  humerus  and  femur  are  nearly  ossified  in  their  whole  length,  the 
extremities  only  being  entirely  cartilaginous.  The  danger  of  separation 
of  the  epiphyses  from  external  violence  or  undue  traction  in  infancy  and 


Fig.  19.—  Lower  end  of  femur  showing  sharp  line  of  demarcation  between  diaphysis  and  epiphyseal 
cartilage,  and  beginning  ossification  in  the  latter.    (Rush  Medical  Museum. ) 


early  childhood  is  apparent.  The  ligamentous  attachments  at  the  articu- 
lations have  been  shown  to  offer  greater  resistance  than  the  epiphyseal 
union,  so  that  separation  at  that  point  would  precede  joint  luxation  or 
bone  fracture  as  a  result  of  rough  handling.  Just  below  the  external 
condyle  of  the  humerus  there  is  a  pit  or  dimple  in  the  skin  which  is  an 
important  landmark,  as  here  the  head  of  the  radius  can  be  felt  rolling 
in  pronation  and  supination  of  the  forearm. 

The  epiphyses  which  meet  at  the  elbow  unite  with  their  shafts  earlier 
than  those  at  the  opposite  ends  of  the  bones,  and  the  foramina  of  the 
nutrient  arteries  are  directed  towards  the  elbow. 

The  bones  of  the  wrists  and  hands  are  nearly  all  cartilaginous  at 
birth.  Owing  to  the  peculiarities  of  fetal  circulation  the  lower  extremi- 
ties have  received  less  nourishment  and  are  not  as  far  developed  as  the 
upper  extremities. 


THE    LARYNX 


27 


THORAX. 

A  characteristic  feature  of  the  infant  thorax  is  the  relation  between 
the  anteroposterior  and  transverse  diameters.  In  the  adult  the  ratio  is 
1 :  3,  while  in  the  infant  it  is  1 : 2  or  even  less.  Another  peculiarity  is 
the  extreme  compressibility.  Owing  to  incomplete  ossification,  carti- 
laginous tissue  predominates  in  the  structure.  It  suggests  in  form  a 
truncated  cone,  and  in  structure,  an  inverted  basket  (Fig.  17). 

The  sternum  is  practically  a  strip  of  cartilage  in  which  there  are 


HHk 

■pN 

1  WP*  ••-* 

rl 

3        % 

vt« 

■    /2l 

*'*H 

jk,      J 

W^^*** 

fh    1 

*mk 

Fig.  20.— Spina  bifida.     (Rush  Medical  Museum.) 

varying  numbers  of  bone-centres.  The  upper  border  of  the  manubrium 
is  usually  about  the  level  of  the  middle  of  the  first  dorsal  vertebra,  a 
higher  position  than  in  adult  life,  when  it  is  at  the  level  of  the  lower 
border  of  the  second  dorsal  vertebra.  It  forms  a  considerable  portion 
of  the  anterior  surface  of  the  thorax. 

The  ribs  are  more  horizontal,  particularly  the  upper  six  or  seven. 
They  are  also  flatter  and  more  elastic  than  in  later  life  (Figs.  16,  20). 


LARYNX. 

The  larynx  extends  from  the  level  of  the  body  of  the  axis  to  the  lower 
border  of  the  fourth  cervical  vertebra.  This  is  fully  two  vertebra3  higher 
than  in  adult  life.     The  chief  characteristics  of  the  larynx,  besides  the 


28  ANATOMY    OF    THE    NEW-BOEN 

location,  are  the  small  size,  the  comparative  slightness  of  the  organ,  and 
the  smooth  rounded  form  of  the  thyroid  cartilage. 

The  high  position  of  the  infant  larynx,  with  the  low  sloping  pharyn- 
geal vault,  must  be  remembered  in  manipulations  such  as  laryngoscopy 
and  intubation,  which  in  many  instances  are  accomplished  with  extreme 
difficulty  in  very  young  children.  On  the  other  hand,  the  shortness  and 
width  of  the  oral  cavity,  the  compressibility  of  the  base  of  the  tongue 
and  flexibility  of  the  neck  render  comparatively  easy,  in  most  cases,  a 
direct  visual  examination  of  the  epiglottis,  the  upper  portion  of  the 
larynx,  arytenoids,  and  vocal  cords.  The  lax  attachment  of  the  larynx 
to  surrounding  structures  allows  of  its  being  brought  more  clearly  into 
view  by  upward  pressure  on  the  cricoid  cartilage,  combined  with  down- 
ward and  forward  pressure  on  the  median  glosso-epiglottidean  ligament, 
by  a  properly  constructed  tongue  depressor. 

TRACHEA. 

As  a  rough  rule  it  may  be  said  that  the  calibre  of  the  trachea  corre- 
sponds to  the  size  of  the  patient's  forefinger.  In  the  foetus  the  trachea 
is  flattened  before  and  behind,  its  anterior  surface  being  even  somewhat 
depressed ;  the  ends  of  the  cartilages  touch ;  and  the  sides  of  the  tube, 
which  now  contains  only  mucus,  are  applied  to  one  another.  The  effect 
of  respiration  is  at  first  to  open  the  trachea,  but  it  still  remains  flat- 
tened in  front,  and  only  later  becomes  convex.  In  consequence  of  the 
high  position  of  the  larynx,  the  cervical  part  of  the  trachea  is  relatively 
longer  at  this  period  of  life,  but  the  increase  in  length  is  somewhat 
diminished  by  the  higher  position  of  the  manubrium.  The  point  of 
bifurcation  of  the  trachea  is  opposite  the  third  dorsal  vertebra,  about 
one  vertebra  higher  at  birth  than  in  the  adult. 

LUNGS. 

Rapid  and  remarkable  changes  occur  in  the  lungs  with  the  commence- 
ment of  respiration.  In  the  foetus  at  full  term  the  lungs,  comparatively 
small,  lie  towards  the  back  of  the  chest,  and  do  not  bulge  forward  at 
the  sides  of  the  heart  (Fig.  21).  After  respiration  has  been  established 
they  expand  and  completely  cover  the  pleural  portion  of  the  pericardium 
and  are  also  in  contact  with  almost  the  whole  extent  of  the  thoracic 
wall,  while  their  previously  thin,  sharp  margins  become  more  obtuse. 
In  utero  the  alveoli  and  small  air-passages  are  collapsed.  At  the  first 
inspiration,  comparatively  little  air  is  taken  into  the  lungs,  because  of 
the  force  necessary  to  overcome  the  adhesions  of  the  sides  of  the  bron- 
chioles and  alveoli ;  but  as  one  full  inspiration  follows  another,  infla- 
tion increases  more  and  more  until  full  distention  is  accomplished. 
If  once  the  lungs  have  been  filled  with  air,  they  are  never  completely 
emptied. 

The  introduction  of  air  and  of  a  greatly  increased  quantity  of  blood 
into  the  fetal  lungs,  converts  their  tissues  from  a  compact,  heavy  sub- 
stance into  a  loose,  light,  rose-pink,  spongy  structure  which  floats.    These 


THE    HEART  29 

changes  occur  first  at  the  anterior  borders  and  proceed  backward  through 
the  lungs;  they,  moreover,  appear  in  the  right  lung  a  little  sooner  than 
in  the  left. 

The  absolute  weight  of  the  lungs,  having  gradually  increased  from 
the  earliest  period  of  development  to  birth,  undergoes  at  that  time,  from 
the  quantity  of  blood  then  poured  into  them,  a  very  marked  addition, 
amounting  to  two-thirds  of  their  previous  weight.  Before  birth  the 
weight  is  48  Gm.,  but  after  complete  expansion  it  has  risen  to  80  Gm. 
Relative  to  body  weight  at  the  end  of  intra-uterine  life  the  weight  of 
the  lungs  is  1 :  70 ;  after  expansion  it  is  1 :  35  or  1 :  40,  a  ratio  not  ma- 
terially altered  through  life.  The  specific  gravity  changes  from  1.056 
to  0.342. 

During  fetal  life  the  alveoli  are  entirely  lined  with  small  granular 
cells,  but  with  the  distention  following  the  first  respiratory  efforts,  many 
of  the  cells  become  transformed  into  large,  thin,  epithelial  elements. 

The  lower  border  of  the  lungs  will  be  found  to  reach  posteriorly  as 
low  as  the  tenth  rib  on  the  right  side,  and  the  eleventh  rib  on  the  left; 
in  the  midaxillary  line  to  the  ninth  rib,  and  in  the  mammillary  line  to 
the  sixth  rib  on  the  left  side,  and  to  the  fourth  or  fifth  on  the  right.  The 
degree  of  approximation  of  the  lungs  anteriorly  is  not  as  close  as  in 
later  life. 

HEART. 

The  average  weight  at  birth  is  twenty  and  one-half  grammes,  or  two- 
thirds  of  an  ounce.  In  the  early  stages  of  fetal  formation  the  heart 
occupies  nearly  the  whole  of  the  thoracic  cavity,  and,  comparatively 
speaking,  is  much  larger  than  it  is  subsequent  to  birth.  The  auricular 
portion  exceeds  the  ventricular,  and  the  right  auricle  is  more  capacious 
than  the  left,  the  right  ventricle  being  also  larger  than  the  left.  The 
organ  is  placed  vertically  within  the  thorax  at  this  early  period.  Just 
before  birth,  however,  these  peculiarities  disappear,  and  the  ventricular 
portion  becomes  the  larger,  the  left  having  the  thicker  walls,  and  the 
whole  organ  rapidly  approaches  its  permanent  condition  for  life.  It  is 
yet  somewhat  larger  in  relation  to  body  weight,  the  ratio  being  at  birth 
1 :  120,  while  in  the  adult  it  is  1 :  160.  In  contrast  with  this,  it  will  be 
remembered  that  one  of  the  characteristic  features  of  the  infantile  thorax 
is  the  shortness  of  its  transverse  diameter.  Since  the  vertical  extent  of 
the  heart  in  relation  to  the  anterior  chest  wall  differs  but  little  in  infants 
and  adults,  it  will  naturally  follow  that  the  transverse .  diameter  of  the 
heart,  as  compared  with  that  of  the  chest,  is  relatively  greater  in  the 
former  than  in  the  latter.  This  naturally  causes  an  extension  outwards 
of  the  position  of  the  apex  beat  in  relation  to  the  nipple.  Hence  it  is 
normal  for  the  apex  beat  to  be  either  in  the  mammillary  line  or  external 
to  it.  Clinicians  are  divided  in  opinion  as  to  the  intercostal  space  in 
which  the  apex  beat  is  to  be  felt  at  birth.  Most  observers  put  it  at  the 
fourth. 

The  internal  structure  of  the  fetal  heart  differs  from  that  of  the  adult 
chiefly  in  having  an  opening  (foramen  ovale)  between  the  auricles,  and 


30 


ANATOMY    OF    THE    NEW-BORN 


in  the  presence  of  the  Eustachian  valve  which  directs  the  blood  from 
the  inferior  vena  cava  through  the  foramen  ovale.  The  latter  generally 
becomes  closed  within  the  first  week  or  ten  days  after  birth,  but  may 
remain  open  longer,  and  in  some  instances  has  been  found  to  be  patent 
in  the  adult.     The  Eustachian  valve  soon  atrophies  after  the  establish- 


Fig.  21.— Lungs,  heart,  thymus  and  thyroid  of  still-born  infant  at  full  term.     (Dr.  J.  D.  Merrill.) 


ment  of  the  function  of  the  lungs  and  the  changed  circulation  of  the 
blood.  Contemporary  with  these  structural  alterations,  there  occur 
changes  in  the  great  vessels,  which  are  requisite  for  the  independent 
circulation  of  the  blood.  The  pulmonary  artery  of  the  foetus,  after 
leaving  the  right  ventricle,  gives  off  the  right  pulmonary  branch,  and 
then  divides  into  two  other  branches,  the  first  of  which  is  as  large  as  the 
pulmonary  artery  itself  and  which  directly  joins  the  aorta  at  the  ter- 
mination of  its  arch,  while  the  other  goes  to  the  left  lung.  The  connect- 
ing branch  between  the  pulmonary  artery  and  the  aorta  is  named  the 
ductus  arteriosus.    It  is  really  the  continuation  of  the  pulmonary  artery. 


FETAL    CIRCULATION 


31 


The  fetal  circulation  consists  of  the  entrance  of  arterial  blood  from 
the  placenta  into  the  body  of  the  child  at  the  umbilicus,  by  means  of  the 
umbilical  vein,  which  ascends  to  the  under  surface  of  the  liver  (Fig.  22). 
Within  this  organ  the  greater  part  of  the  blood  first  circulates  through 
the  branches  of  the  portal  and  hepatic  veins,  and  thence  passes  to  the 
inferior  vena  cava,  but  a  portion  of  the  blood  conveyed  by  the  umbilical 


Right  Com.  Carotid 


Left  Com.  Carotid 
Left  Subolar 


Ductus 
nteriosus 


Left  Auricle 


Left  Ventricle 


Intenal  ITiaa 


Fig.  22.— Fetal  circulation.     (Gray.) 

vein  is  conducted  by  a  small  vein  directly  to  the  inferior  vena  cava, 
without  passing  through  the  substance  of  the  liver ;  this  vessel  is  called 
the  ductus  venosus. 

The  inferior  vena  cava  empties  all  its  blood  into  the  right  auricle, 
whence  it  is  directed  by  the  Eustachian  valve  through  the  foramen  ovale 
into  the  left  auricle.  From  the  left  auricle  it  passes  into  the  left  ven- 
tricle, and  thence  by  means  of  the  aorta  it  is  distributed  chiefly  to  the 


32  ANATOMY    OF    THE    NEW-BORN 

head,  neck,  and  upper  extremities.  The  more  immediate  supply  of  pure 
blood  to  these  parts  accounts  for  their  greater  proportionate  develop- 
ment at  birth.  The  venous  blood  from  the  upper  part  of  the  body  is 
returned  into  the  superior  vena  cava  and  by  it  to  the  right  auricle,  which 
it  passes  to  the  right  ventricle.  Prom  the  latter  it  issues  by  the  pulmonary 
artery,  and  is  chiefly  conveyed  by  its  continuation,  the  ductus  arteriosus, 
into  the  upper  portion  of  the  descending  aorta,  where  it  mixes  with  a 
portion  of  the  blood  from  the  left  ventricle.  From  the  descending  aorta 
the  blood  passes  through  the  abdominal  aorta  into  the  iliac  arteries. 
The  external  iliac  arteries  carry  part  of  this  blood  to  the  lower  ex- 
tremities, but  the  most  of  it  is  returned  to  the  placenta  by  means  of 
the  hypogastric  arteries,  which  are  the  continuation  of  the  superior  vesi- 
cal branches  of  the  internal  iliac.  They  pass  out  at  the  umbilicus, 
where,  under  the  name  of  the  umbilical  arteries,  they  twine  around  the 
umbilical  vein  in  the  substance  of  the  cord,  and  return  their  impure 
blood  to  the  placenta  to  be  reoxygenated. 

The  umbilical  vein  and  ductus  venosus,  after  ligation  at  birth,  atro- 
phy and  become  converted  into  a  fibrous  cord  which  constitutes  the  round 
ligament  of  the  liver.  The  coagula  usually  disappear  from  these  vessels 
within  five  days.  The  ductus  arteriosus  and  hypogastric  arteries  also 
contract  after  birth  and  become  closed, — the  former  usually  within  the 
first  ten  days,  and  the  latter  within  the  first  three  or  four  days.  The 
remains  of  the  ductus  arteriosus  constitute  the  ligamentum  arteriosum, 
which  is  attached  to  the  concavity  of  the  aorta.  The  bands  resulting 
from  the  obliteration  of  the  hypogastric  arteries  form  the  lateral  false 
ligaments  of  the  bladder. 

A  review  of  the  development  of  the  embryonic  heart  sheds  some  light 
on  the  character  of  many  congenital  defects.  It  is  claimed  that  pulsa- 
tion has  been  noted  in  the  human  embryo  as  early  as  the  fifth  day,  the 
entire  circulatory  apparatus  being  then  represented  by  a  few  cells. 
From  this  in  a  few  days  is  evolved  a  tube,  the  foundation  of  the  heart 
and  great  vessels.  By  the  end  of  the  second  week  is  seen  an  S-shaped 
organ  which  is  still  monolocular  with  two  sets  of  vessels,  the  primitive 
veins  and  arteries.  At  the  fourth  week  the  cavity  is  partly  divided 
by  the  growing  septum  into  two  compartments,  one  for  the  admission, 
the  other  for  the  discharge  of  blood.  By  the  end  of  the  eighth  week  a 
membranous  process,  which  appeared  early  at  the  lower  part  of  the 
apex  and  at  the  margins  of  the  orifices  of  exit,  has  developed  into  a 
septum  dividing  the  great  efferent  vessel  into  the  aorta  and  pulmonary 
artery  and  forming  the  interventricular  partition.  The  last  part  of 
this  septum  to  be  completed  is  the  upper  portion,  lying  immediately 
below  the  auricoloventricular  walls.  During  this  time  the  auricular 
portion  of  the  heart  is  divided  in  a  similar  manner  into  right  and  left 
chambers  by  the  interauricular  process,  which  pushes  inward  and  is 
not  completed  until  after  birth,  the  foramen  ovale  being  the  last  part 
to  close.  The  septum  ventriculorum  also  not  infrequently  shows  at  birth 
a  foramen.    When  present  it  is  invariably  in  its  upper  portion.    By  far. 


THYMUS    GLAND  33 

the  commonest  defect  in  development  is  seen  at  the  pulmonary  orifice 
either  as  (1)  malformation  of  its  valves,  not  infrequently  two  only 
being  found,  or  the  three  coalescing  in  the  form  of  a  perforated  circular 
diaphragm,  or  (2)  there  may  be  a  narrowing  below  the  valves,  a  stenosis 
of  the  conus.  It  is  easy  to  understand  how  a  primary  stenosis  of  the 
pulmonary  orifice  or  conus  might  influence  the  development,  not  only 
in  the  septa  but  in  the  muscular  walls  of  the  right  ventricle,  through 
the  obstruction  to  outflow  from  this  cavity.  In  fact,  a  patulous  septum 
ventriculorum  is  usually  associated  with  pulmonary  stenosis  with  accom- 
panying hypertrophy  of  the  right  ventricle  (Fig.  142). 

Occasionally  arrest  of  development  in  the  intervascular  septum  leaves 
a  common  trunk  or  chamber  attached  to  the  ventricular  portion  of  the 
heart,  from  which  arises  the  aorta  and  pulmonary  vessels  (Fig.  141). 

An  entire  absence  of  the  septum  ventriculorum  has  been  observed, 
as  also  has  that  of  the  auricles ;  so  that  bilocular  and  trilocular  hearts 
are  among  the  anomalies  of  arrested  development,  with  a  great  variety 
of  abnormalities  in  the  position  and  formation  of  the  vessels. 

THYMUS   GLAND. 

This  is  a  temporary  organ  which  reaches  its  greatest  size  about  the 
end  of  the  second  year.  It  appears  as  a  narrow,  elongated,  glandular 
body,  situated  partly  in  the  thorax  and  partly  in  the  lower  region  of  the 
neck  (Fig.  21).  Below,  it  lies  in  the  upper  anterior  mediastinal  space, 
behind  the  sternum  as  far  down  as  the  fourth  rib  cartilage  and  in  front 
of  the  great  vessels  and  pericardium ;  above,  it  extends  upwards  upon 
the  trachea  in  the  neck  as  high  as  the  lower  border  of  the  thyroid  carti- 
lage. Considerable  variation  in  size  and  shape  has  been  found.  The 
color  is  a  grayish-pink,  the  consistence  soft  and  pulpy,  and  the  surface 
is  distinctly  lobulated.  It  consists  of  two  lateral  lobes  which  touch  each 
other  along  the  middle  line.  Occasionally  the  whole  body  forms  a  single 
mass  and  often  there  is  an  intermediate  lobe.  It  measures  about  sixty 
millimetres  (2%  inches)  in  length,  thirty-seven  millimetres  (1%  inches) 
in  width,  about  eight  millimetres  in  thickness,  and  weighs  from  five  to 
fourteen  grammes. 

THYROID    GLAND. 

The  thyroid  at  birth  is  of  relatively  large  size,  being  in  proportion  to 
body  weight  as  1 :  240 ;  while  in  the  adult  it  is  1 :  1800.  There  are  two 
lateral  lobes  united  towards  their  lower  ends  by  a  transverse  portion 
called  the  isthmus  (Fig.  21).  Each  lateral  lobe  lies  on  the  side  of  the 
trachea,  extending  from  the  fifth  or  sixth  ring  to  the  thyroid  cartilage. 
The  isthmus  commonly  lies  across  the  second,  third,  and  fourth  rings  of 
the  trachea. 

It  is  extremely  vascular,  its  blood  supply  not  being  exceeded  by  that 
of  any  other  equal  area.  Its  freely  anastomosing  veins  (the  superior, 
middle,  and  inferior  thyroid)  open  directly  into  the  internal  jugular 
and  innominate. 


34  ANATOMY    OF    THE    NEW-BORN 

Like  the  thymus  the  thyroid  has  no  duct  after  birth.  It  has  recently 
been  claimed  that  the  remains  of  an  embryonic  duct  have  been  found 
leading  to  the  foramen  caecum  at  the  angle  formed  by  the  circumvallate 
papillae.  To  the  occasional  persistency  of  this  duct,  a  causative  relation- 
ship has  been  claimed  for  the  rare  development  of  accessory  thyroid 
tissue  found  as  tumors  at  the  base  of  the  tongue. 

Variations  in  the  size,  shape,  and  number  of  the  lobes  of  the  thyroid 
gland  are  common.  At  times  the  gland  consists  of  two  separate  parts, 
one  on  each  side  of  the  trachea,  or  there  may  be  only  one  lateral  lobe, 
or  the  three  portions  may  not  be  united. 

The  occurrence  of  accessory  glands  is  of  clinical  interest,  inasmuch 
as  it  helps  to  explain  in  certain  cases  the  lessened  severity  of  the  symp- 
toms following  extirpation  of  the  gland.  These  accessory  glands  are 
found  in  the  region  of  the  aorta,  in  the  supraclavicular  fossa?,  and  to  the 
side  of  and  behind  the  pharynx  and  large  vessels  of  the  neck. 

Other  glandular  bodies,  known  as  parathyroids,  are  found  in  close 
relation  to  the  thyroid  gland  just  behind  the  lateral  lobes.  There  may 
be  one  or  two  of  these  bodies  on  either  side,  varying  in  size  but  averaging 
in  length  seven  millimetres,  in  breadth  two  to  three  millimetres,  and  in 
thickness  one  and  one-half  millimetres.  They  differ  from  the  thyroid 
not  only  in  structure  but  also  in  function,  the  latter  fact  having  been 
demonstrated  by  the  differing  effects  following  their  removal. 

BRONCHIAL    GLANDS. 

The  bronchial  lymphatic  glands  are  found  in  three  groups,  the  loca- 
tion of  which  is  of  interest  on  account  of  their  relationship  to  adjacent 
vessels  and  nerves.  The  first  group  is  in  intimate  relation  with  the 
trachea,  the  superior  vena  cava,  recurrent  laryngeal  and  pneumogastric 
nerves;  the  second  set  is  found  at  the  bifurcation  of  the  trachea  and 
roots  of  the  lungs  (hilus  glands),  where  their  enlargement  would  en- 
croach on  the  oesophagus,  pneumogastric  nerves,  and  the  aorta;  the 
third  follows  the  larger  bronchioles  into  the  substance  of  the  lungs,  along 
with  the  bronchial  and  pulmonary  vessels  and  nerves. 

DIAPHRAGM. 

The  diaphragm  forms  a  muscular  partition  between  the  chest  and 
abdomen.  It  is  described  as  occupying  a  higher  position  than  in  adults. 
The  lungs  in  their  pleura?  rest  upon  the  muscular  portions,  while  the 
heart  in  the  pericardium  lies  above  the  central  tendon.  On  each  side  of 
the  ensiform  cartilage  is  a  triangular  space  which  gives  passage  to  the 
vessels  to  the  anterior  mediastinum.  Occasionally  this  becomes  the  seat 
of  a  diaphragmatic  hernia. 

ABDOMEN. 

In  the  child  at  full  term  and  for  the  first  two  years  the  umbilicus 
marks  the  middle  of  the  long  axis  of  the  body.  The  cord  usually  drops 
off  at  the  end  of  five  to  seven  days  (occasionally  this  period  is  much 
longer,  fourteen  to  twenty-three  days),  leaving  a  red  and  moist  surface. 


Fig.  23.— Stomachs  of  the  new-born. 


ALIMENTARY    TRACT  35 

THE    ALIMENTARY    TRACT. 

When  the  alimentary  canal  first  assumes  a  tubular  form  it  is  a 
simple,  straight  cylinder,  placed  in  front  of  the  vertebral  canal,  attached 
to  it  and  to  the  rest  of  the  embryo  by  a  membranous  fold  or  rudimentary 
mesentery.  By  degrees  the  canal,  growing  in  length,  becomes  looped 
at  the  centre,  and  straight  at  the  upper  and  lower  ends,  while  the  part 
destined  to  be  the  stomach  is  dilated.  This  gradually  turns  on  its  side, 
and  the  border  which  is  connected  to  the  spine  by  a  membranous  fold 
falls  to  the  left. 

(ESOPHAGUS. 

The  oesophagus,  commencing  at  the  termination  of  the  pharynx  oppo- 
site the  body  of  the  fourth  cervical  vertebra  and  the  upper  border  of  the 
thyroid  cartilage,  passes  down  through  the  posterior  mediastinum  and 
enters  the  stomach  a  little  to  the  left  of  the  median  line.  It  presents 
three  slight  constrictions,  the  most  marked  being  at  the  cardiac  orifice 
where  it  passes  through  the  diaphragm. 

The  first  constriction  is  opposite  the  body  of  the  first  dorsal  vertebra, 
a  favorite  seat  for  the  lodgement  of  foreign  bodies  (Fig.  133). 

STOMACH. 

Contrary  to  generally  accepted  statements,  the  general  form  and 
position  of  the  stomach  are  very  similar  to  those  of  the  empty  and  col- 
lapsed stomach  of  the  adult,  but  in  consequence  of  the  large  size  of  the 
left  lobe  of  the  liver,  the  whole  of  the  anterior  surface  is  usually  covered 
by  that  organ.  When  the  stomach  is  filled,  the  movement  of  its  pylorus 
towards  the  right  side  is  probably  impeded  by  the  large  liver,  thus 
tending  to  make  the  axis  more  nearly  vertical.  The  fundus  is  usually 
less  pronounced  and  the  valvular  constriction  of  the  cardiac  orifice  is 
wanting,  allowing  easy  regurgitation  of  the  contents.  The  average  ca- 
pacity at  birth  is  less  than  an  ounce  (Fig.  23).  The  thinness  of  its  walls 
is  noticeable  and  its  mucous  membrane  presents  numerous  slight  eleva- 
tions due  to  the  accumulation  of  lymphoid  tissue  which  resemble  in 
appearance  the  solitary  follicles  of  the  intestines. 

INTESTINES. 

In  the  early  fcetus  the  small  intestine  occupies  the  right  side  of 
the  abdomen,  while  the  large  is  represented  by  a  straight  tube  that 
passes  on  the  left  side  vertically  from  the  region  of  the  umbilicus  to 
the  pelvis. 

At  full  term  the  duodenum  forms  a  loop  very  suggestive  of  the  mature 
arrangement, — namely,  with  its  openings  at  the  highest  level.  As  seen  in 
casts,  it  presents  more  of  a  V-shape  than  the  modified  horseshoe  of  later 
life.  The  ends  do  not  show  the  marked  constrictions  of  the  more 
advanced  organ  and  the  lining  membrane  does  not  present  so  distinctly 
the  numerous  folds,  valvules  conniventes. 

The  division  into  jejunum  and  ileum  is  arbitrary,  but  the  upper 


36 


ANATOMY    OF    THE    XEW-BORX 


part  of  the  small  bowel  usually  occupies  the  left  iliac  fossa,  and  the 
lower  the  right. 

The  cascum,  situated  in  early  fetal  life  near  the  umbilicus,  ascends 
in  the  abdomen  towards  the  left  hypochondrium.  It  next  passes  trans- 
versely to  the  right  hypochondrium,  descending  thence  into  the  iliac 
fossa.  It  may  find  permanent  lodgement  at  any  time  during  its  develop- 
ment, thus  explaining  the  many  anomalous  situations  of  this  viscus. 

The  length  of  the  small  intestine  is  given  at  2.87  M. ;  the  caecum  and 
colon  measure  30.5  Cm.,  exclusive  of  the  sigmoid  flexure,  which  is  about 
25,3  Cm,  in  length.     The  latter  is  curved  in  form  and  lies  chiefly  in  the 


Fig.  24.— Mesial  section,  showing  several  folds  of  the  infant  rectum,    yaymington.) 

abdominal  cavity,  though  it  often  presents  great  variations  both  in  form 
and  extent,  at  times  extending  in  an  irregular  loop  as  high  as  the 
umbilicus. 

The  shallowness  of  the  pelvis  (Fig.  16),  the  slight  concavity  of  the 
sacrum,  and  the  amplitude  of  the  rectal  tissues,  give  to  the  upper  part 
of  the  rectum  several  lateral  flexures,  so  that  a  mesial  section  of  the 
infant  pelvis  includes  not  infrequently  three  or  four  folds  of  the  rectum 
(Fig.  24).  Its  attachments  to  surrounding  structures  do  not  extend 
as  high  up  in  the  pelvis  as  in  later  development.  These  conditions,  with 
the  more  vertical  position  of  the  lower  third,  offer  some  explanation  of 
the  proneness  to  prolapsus  in  infancy. 


LIVER. 

The  formation  of  this  important  glandular  organ  begins  at  a  very 
early  period  of  fetal  life  by  a  process  from  the  intestinal  tube.     It  was 


LIVER 


37 


probably  at  first  a  symmetrical  organ,  but  became  pushed  to  the  right 
by  the  rapid  growth  of  the  other  abdominal  viscera.  Its  growth  is  very 
rapid,  so  that  at  the  third  or  fourth  week  of  intrauterine  existence  it 
constitutes  nearly  one-half  of  the  entire  body  weight,  almost  filling  the 
abdominal  cavity.  At  birth  its  relative  weight  to  that  of  the  body  is 
one  to  eighteen. 

The  superior  border  of  the  right  lobe  extends  in  the  midscapular 
line  to  the  seventh  rib,  in  the  midaxillary  to  the  sixth,  and  in  the  mid- 
clavicular line  to  the  fifth  rib.  Its  inferior  border  extends  in  the  median 
line  almost,  and  occasionally  quite  to  the  umbilicus.  Generally  speaking 
its  lower  border  may  be  defined  by  a  line  from  the  lowest  point  of  the 
ninth  rib  to  the  eighth  left  costochondral  junction.  Recent  observations 
show  that  enlargement  of  the  liver  is  a  very  common  condition  in  the 
new-born.  The  lateral  margin  of  the  left  lobe  may  be  found  an  inch  to 
the  left  of  the  median  line,  or  it  may  fill  nearly  the  entire  left  hypo- 


Fig.  25. — Large  liver  in  the  new-born. 


chondrium  (Fig.  25),  completely  covering  the  stomach.  The  upper 
border  of  the  left  lobe  is  difficult  to  outline  because  its  substernal  dulness 
is  continuous  with  that  of  the  heart. 


SPLEEN. 

At  birth  the  average  weight  of  the  spleen  is  one-fourth  of  an  ounce 
(8  Gm.).  Being  situated  in  close  apposition  to  the  posterior  and  de- 
scending wall  of  the  diaphragm,  opposite  the  ninth,  tenth,  and  eleventh 
ribs,  and  covered  anteriorly  by  the  large  end  of  the  stomach,  it  is  seldom 
revealed  by  palpation  or  percussion.  Not  infrequently  a  supernumerary 
spleen  is  found  varying  in  diameter  from  five  to  fifteen  millimetres, 
sometimes  attached  to,  at  other  times  having  no  connection  with,  the 
primary  organ  (Fig.  26).  Palpability  of  the  spleen  is  evidence  of  its 
enlargement. 

PANCREAS. 

The  pancreas  is  well  formed  by  the  second  month  of  fetal  life,  at 
about  the  same  time  as  the  salivary  glands,  which  it  resembles  in  arrange- 
ment and   function. 


38 


ANATOMY    OF    THE    NEW-BORN 


KIDNEYS. 

The  kidneys  at  birth  are  comparatively  large,  while  the  lumbar 
part  of  the  spine  is  relatively  small.  It  is  not  surprising  that  they 
extend  lower  down  in  relation  to  the  vertebrae  and  the  iliac  crests  than 
in  the  adult.  At  all  ages  the  kidneys  are  found  with  their  upper  por- 
tions partly  concealed  behind  the  twelfth  rib.  Frozen  sections  show 
that,  contrary  to  accepted  opinion,  the  right  is  frequently  as  high  as  the 
left  and  not  crowded  down  by  the  large 
liver,  its  position  being  posterior  to  that 
organ. 

A  gross  peculiarity  is  the  distinct 
lobulation  of  the  surface,  the  lobules 
corresponding  in  number  with  the  inter- 


Fig.  26.— Spleen,  with  a  supernumerary, 
and  pancreas. 


Fig.  27. — Lobulated  kidney  of  the  new-bom. 


nal  pyramidal  divisions  (Fig.  27).     Occasionally  the  kidneys  are  joined 
at  one  extremity,  producing  the  horseshoe  form. 


SUPRARENALE. 

In  the  foetus  the  suprarenal  capsules  are  larger  than  the  kidneys  and 
at  birth  are  relatively  much  larger  than  in  adult  life.  They  are  very 
vascular,  receiving  their  blood  supply  from  the  aorta,  phrenic  and  renal 
arteries,  whose  branches  converge  to  form  a  capillary  plexus  in  the 
medullary  substance  of  the  gland.  The  suprarenal  veins  on  the  right 
side  empty  into  the  inferior  vena  cava,  and  on  the  left,  into  the  left  renal 


BLADDER 


39 


vein.     They  are  well  supplied  with  lymphatic  vessels  and  nerves,  the 
latter  being  derived  chiefly  from  the  renal  and  solar  plexuses. 

Masses  of  gland  tissue  resembling  the  adrenals  are  frequently  found 
in  adjacent  parts  of  the  body, — as  the  cortex  of  the  kidneys,  liver,  spleen, 
and  testicles.  They  were  formerly  mistaken  for  masses  of  fat,  but  are 
now  generally  considered  accessory  suprarenal  glands  or  "  rests." 

BLADDER. 

The  bladder  is  derived  from  the  urachus,  which  is  part  of  a  mem- 
branous sac  (the  allantois)  appended  to  the  umbilicus  in  the  early  fetal 
state.     At  first  the  shape  of  the  bladder  is  an  elongated  tube  situated 


Fig.  28.— Mesial  section  of  infant,  4  months.     Distended  bladder,  showing  extent  of  peritoneal 
investments.    (Symington.) 

in  the  lower  part  of  the  abdomen.  In  the  new-born  the  capacity  is  from 
two  to  four  drachms  (7.5-15  C.c).  It  is  usually  described  as  an  abdomi- 
nal organ,  but  this  is  not  strictly  accurate.  The  small  pelvic  cavity  is 
occupied  mainly  by  the  rectum  and  there  is  little  room  for  the  bladder, 
but  if  a  line  be  drawn  from  the  sacral  promontory  to  the  top  of  the 
symphysis,  one  half  of  the  bladder  will  lie  below  it.  The  pelvis  is  more 
oblique,  so  that  the  whole  organ  lies  above  the  pubic  crest,  and  it  is  so 
loosely  attached  to  the  pelvic  walls  that  but  little  force  is  required  to 
push  it  into  the  abdomen. 


40  ANATOMY    OF    THE    NEW-BORN 

It  is  ovoid  in  shape  when  distended,  with  the  larger  end  directed 
downwards  and  backwards.  There  is  no  marked  fundus.  The  urethral 
orifice  is  at  the  level  of  the  upper  border  of  the  symphysis.  The  bladder 
extends  forwards  and  upwards  in  close  contact  with  the  pubes,  until  it 
reaches  the  anterior  abdominal  wall,  against  which  it  lies  until  near  the 
umbilicus.  The  anterior  surface  is  entirely  uncovered  by  the  perito- 
neum; posteriorly,  the  peritoneum  reaches  as  low  as  the  level  of  the 
orifice  of  the  bladder  (Figs.  24  and  28). 

URETHRA. 

The  infant  urethra  in  the  male  averages  six  centimetres  (2%  inches). 
It  is  delicate  in  structure,  quite  distensible,  and  shows  a  marked  con- 
striction at  the  meatus, — points  to  be  remembered  in  the  use  of  in- 
struments. 

The  prostate  gland  is  small,  its  weight  being  about  thirteen  grains 
(0.85-Gm.). 

At  birth  the  glans  penis  is  closely  invested  by  the  prepuce,  which  is 
frequently  elongated,  presenting  a  very  small  opening.  The  cohesion 
of  the  mucous  membrane  lining  the  prepuce,  with  that  covering  the 
glans,  may  be  so  firm  as  to  border  upon  the  pathological. 

TESTICLES. 

The  testicles  are  formed  below  the  kidneys  in  the  lumbar  region,  and 
at  about  the  eighth  month  of  intrauterine  life  present  at  the  internal 
openings  of  the  inguinal  canals,  which  are  short  and  straight,  gradually 
finding  their  way  into  the  scrotum. 

The  descent  is  accompanied  by  formation  of  the  cord  in  an  aggrega- 
tion of  its  vas  deferens,  veins,  arteries,  lymphatics,  nerves,  and  gelatinous 
tissue.  The  process  of  peritoneum  which  passes  through  the  inguinal 
canal  precedes  the  descent  of  the  testicle,  although  it  is  not  pushed  before 
it,  as  formerly  described,  for  in  cases  where  the  testicles  have  remained 
within  the  abdomen,  the  vaginal  process  may  occupy  its  normal  position 
in  the  scrotum.  Ordinarily  this  process  after  birth  becomes  adherent  to 
adjacent  structures  and  is  separated  from  the  rest  of  the  peritoneum, 
becoming  gradually  blended  with  the  cord  above  the  testicle. 

OVARIES. 

In  early  fetal  life  the  location  of  the  ovaries  corresponds  to  that  of 
the  testicles.  At  birth  they  have  only  descended  to  the  brim  of  the  pelvis, 
with  the  uterine  ends  projecting  into  its  cavity.  They  are  whitish, 
smooth,  and  elongated  bodies  attached  to  the  free  ends  of  the  ample 
convoluted  tubes,  the  latter  showing  but  one  or  a  very  few  fimbria? 
(Fig.  29).  Ova  are  developed  at  an  early  period  in  the  life  of  the 
embryo  from  germinal  epithelium,  and  it  is  doubtful  if  their  formation 
proceeds  after  birth.  It  is  stated  that  there  are  70,000  egg  cells  in  the 
human  ovary  at  birth. 


BRAIN  41 

UTERUS. 

The  uterus  at  birth  is  from  two  and  one-half  to  three  centimetres 
(1— 114  inches  long  (Fig.  29).  There  is  no  fundus,  but  the  body  ap- 
proaches the  two-horned  form  prevalent  in  lower  animals.  The  cervix  is 
longer,  thicker,  and  firmer  than  the  body.  On  opening  the  uterus  the 
arbor  vitae  will  be  found  extending  along  its  whole  length,  and  there  is 
no  constriction  corresponding  to  the  internal  os.  The  urethra  and  vagina 
of  the  infant  are  comparatively  large  and  distensible. 

MAMMARY    GLANDS. 

At  birth  these  are  from  five  to  eight  millimetres  (one-fifth  to  one-third 
inch)  in  diameter.  The  nipple  with  dartos  is  well  formed  and  the 
secreting  structure  is  represented  by  slightly  ramified  ducts  which  con- 
tain a  milky  fluid. 

BRAIN. 

The  delevopment  and  growth  of  the  brain  is  very  active  during  intra- 
uterine life,  so  that  at  birth  this  organ  is  of  relatively  large  size,  and  in 
general  form  and  relation  of  its  parts  it  presents  a  close  approximation 
to  that  of  the  adult.  The  anterior  lobes  and  cerebellum,  however,  are 
relatively  small.  The  ratio  of  brain  weight  to  that  of  the  body  at  birth 
is  1 :  8. 

The  dura  is  quite  closely  adherent  to  the  skull,  so  that  extravasations 
can  with  difficulty  take  place  between  them.  The  blood-vessels  of  the  pia 
mater  are  exceedingly  delicate,  which  partly  accounts  for  the  frequency 
of  cerebral  hemorrhage  at  birth. 

The  fissure  of  Sylvius  is  higher  and  that  of  Rolando  less  vertical 
than  in  the  adult.  The  convolutions  and  sulci  are  somewhat  shallow 
and  simple.  In  fact,  at  an  early  stage  of  embryonic  life  the  surface  is 
quite  smooth. 

The  brain  substance  is  of  a  nearly  uniform  whitish  color.  On  account 
of  its  large  percentage  of  water,  it  is  of  a  soft,  pulpy  consistency,  re- 
quiring great  care  in  handling. 

SPINAL    CORD. 

In  the  earlier  months  of  fetal  life,  the  medulla  spinalis  occupies  the 
whole  length  of  the  vertebral  canal,  but  as  development  proceeds,  the 
spinal  column  grows  more  rapidly  than  the  contained  cord,  so  that  the 
latter  appears  as  if  drawn  up,  until  at  birth  it  terminates  at  the  third 
lumbar  vertebra. 


CHAPTER  II 
NORMAL  GROWTH  AND  DEVELOPMENT 

EARLY   INFANCY 

For  the  purpose  of  discussion,  growth  and  development  may  be 
divided  arbitrarily  into  many  periods,  but  certain  fairly  well  defined 
physiologic  processes  suggest  five  epochs, — viz.,  early  and  late  infancy, 
early  and  late  childhood,  and  youth. 

Early  infancy  would  correspond  with  the  Sdugling  Salter,  or  sucking 
period,  of  the  Germans.  The  first  dentition  is  usually  complete  at  the 
end  of  thirty  months,  which,  in  this  classification,  would  mark  the  begin- 
ning of  childhood.  Late  childhood,  commencing  at  the  appearance  of 
the  permanent  teeth,  or  about  the  sixth  year,  extends  to  puberty. 

The  importance  of  a  familiarity  with  the  rate  of  growth  during  the 
different  periods  of  infancy  and  childhood,  cannot  be  overestimated,  as 
it  is  well  known  that  irregularities  in  the  growth  are  frequently  the  first 
intimations  of  disturbed  nutrition  or  developing  disease. 

Increase  in  weight  and  length,  and  the  measurements  of  the  different 
members,  bear  normally  a  certain  constant  relation  at  different  periods 
of  life.  No  period  of  extrauterine  life  compares  in  rapidity  of  growth 
with  that  of  the  first  six  months. 

Taking  the  birth  weight  as  3280  Gm.  (about  7*4  pounds)  statistics 
show  that  the  loss  of  weight  in  the  first  three  days  is  about  ten  per  cent. 
This  is  usually  regained  by  the  end  of  the  first  week.  The  reason  for 
this  early  loss  is  quite  apparent.  It  is  due  partly  to  the  loss  of  fluids 
from  the  viscera  as  well  as  from  the  surface  of  the  body,  and  partly 
to  consumption  of  stored  material  prior  to  the  establishment  of  lactation. 
This  consumption  is  rapid,  as  there  is  increased  metabolism  incident  to 
a  greater  muscular  and  circulatory  activity  in  the  presence  of  an  in- 
creased supply  of  oxygen.  From  the  examination  of  many  tables  it 
appears  that  the  normal  infant  doubles  his  birth  weight  by  the  sixth 
month  and  trebles  it  soon  after  the  twelfth  month,  growth  being  most 
rapid  during  the  first  four  months  of  life. 

The  following  charts  from  Holt  give  a  fair  idea  of  the  weight  curves 
for  the  first  three  weeks  and  twelve  months,  respectively  (Figs  30 
and  31). 

LENGTH 

Accepting  the  average  length  at  birth  as  48.2  centimetres  (19  inches), 
we  find  a  somewhat  regular  ratio  of  increase  vhich  doubles  the  birth 
length  at  the  end  of  the  fourth  year,  increase  in  length  as  in  weight 
being  most  rapid  in  the  early  months  of  life.  The  increase  during  the 
first  year  (about  half  of  the  initial  length)  is  nearly  double  that  of  any 
succeeding  year. 

A  notable  difference  in  ratio  of  growth  appears  during  acute  febrile 
42 


WEIGHT 


43 


Fig.  30. 


WEIGHT  CHART. 
Name, Date  of  Birth, .j8g 

i 

J3 
_J 

MONTH  OF  AGE. 

123456          78          9        10        11      12 

10890 
10130 
9980 
9530 
90/0 
8620 
81  GO 
7710 
7260 
6800 
6350 
6900 

tm 

1990 
4510 
4080 
S630 
3180 
8720 
£270 

24 
23 
22 
21 

20 

10 
IS 
17 
16 
15 
14 
13 
12 
11 
10 
9 
8 
7 
C 
5 

1 

i 

1 1 

I 

. 

- 

1 

1 

n  j 

^ 

. 

_ 

- 

_ 

I 

-j— 

d 

■ 

-   ■ 

;  i 

1 1 

I 

1 1  i 

1 1 

i 

1 1 1 

i 

"1 

i 

i 

I 

_ 

1 

!  1 

1 1 

i  J 

Fig.  31. 


PATTEST  WEIGHT  CHAET. 
Name, Date  of  Birth, 1S9 

Gme. 

Lbs. 

I 

2 

3 

1 

5 

6 

7 

8 

9 

10 

11 

12 

13 

u 

IS 

16 

17 

18 

19 

20 

«20 

1310 
1200 
1080 
3970 
3850 
3710 
3630 
3510 
3100 
3290 
3180 
3060 
2910 
2830 
2720 
2610 
2190 
2380 

9« 

9 

8% 

834 
8 

7* 
7>$ 
W* 

7 
6fc 
6% 
VA 

6 
5fc 
5>* 
VA 

44 


NORMAL    GROWTH    AND    DEVELOPMENT 


disorders,  as  the  exanthemata,  when  the  weight  invariably  diminishes, 
while  the  increase  in  length  continues  or  may  even  be  accelerated.  Fig. 
32  illustrates  phenomenal  growth  in  length  during  typhoid  fever  in  a 
child  of  nine  years. 

The  average  increase  of  the  second  year  is  about  ten  centimetres  (4 
inches),  and  from  that  on  to  the  age  of  eleven  or  twelve  years  from  five 
to  eight  centimetres  (2-3  inches)  annually.  After  this  period,  for  a  year 
or  two,  for  the  only  time,  the  height  of  girls  exceeds  that  of  boys. 

Development  in  length  is  most  rapid  in  the  lower  extremities,  which 


Fig.  32.— Linea  albicantes  after  severe  typhoid  in  previously  fat  child.     (Dr.  S.  W.  Kelley.) 


fact  constantly  moves  the  centre  of  the  body  downward  from  the  umbili- 
cus, until  maturity,  when  the  centre  is  about  the  upper  border  of  the 
symphysis. 

Exceptions  to  this  rule  are  seen  in  achondroplasia,  rhachitis,  and  cre- 
tinism, where  the  long  bones  show  retardation  in  longitudinal  growth. 

Porter's  observations  of  a  large  number  of  school  children  of  St. 
Louis,  from  six  to  sixteen  years,  show  an  average  of  nearly  two  pounds 
lower  weight  than  the  following  table. 

Of  extreme  interest  is  the  relative  growth  of  head  and  chest  in  infancy 
and  childhood.  Taking  the  average  circumference  of  heads  at  birth 
(boys)  measured  at  the  level  of  the  occipital  protuberance,  as  35.5  centi- 
metres (13.9  inches),  and  that  of  the  thorax  just  below  the  nipples  and 
the  angles  of  the  scapulas  as  34.2  centimetres  (13.4  inches),  we  find  the 
ratio  steadily  decreasing  until  the  two  circumferences  are  equal  before 
the  end  of  the  second  year.  From  this  on  the  ratio  is  reversed,  the  chest 
increasing  more  rapidly  up  to  maturity. 

The  increase  in  the  circumference  of  the  head  in  early  life  is  remark- 
able, and,  like  that  of  the  body  weight,  is  more  rapid  during  the  first  year. 
Reference  to  the  foregoing  table  shows  the  average  growth  of  the  head 
during  the  first  six  months  to  be  8  centimetres  (3.3  inches)  ;   during  the 


WEIGHT    AND    DIMENSIONS 


45 


Table  from  Boas,   showing  Weight,  Height,  and   Circumference  of  Chest  and 
Head  from  Birth  to  the  Kim    Year. 


Age 


Birth 
6  months 
12  months 
18  months 

2  years 

3  years 

4  years 

5  years 

6  years 

7  years 
'8  years 

9  years 

10  years 

11  years 

12  years 

13  years 

14  years 

15  years 

16  years 


Sex 


Boys 
Girls 

Boys 
Girls 

Boys 
Girls 

Boys 

Girls 

Boys 
Girls 

Boys 
Girls 

Boys 
Girls 

Boys 
Girls 

Boys 

Girls 

Bovs 
Girls 

Boys 
Girls 

Boys 

Girls 

Boys 
Girls 

Boys 
Girls 

Boys 

Girls 

Boys 
Girls 

Boys 

Girls 

Boys 

Girls 

Boys 

Girls 


Weight 


Pounds 

7.55 
7.1(5 

16.0 
15.5 

20.5 
19.8 

22.8 
22.0 

26.5 
25.5 

31.2 
30.0 

35.0 
34.0 

41.2 
39.8 

45.1 
43.8 

49.5 
48.0 

54.5 
52.9 

60.0 
57.5 

66.6 
64.1 

72.4 
70.3 

79.8 
81.4 

88.3 
91.2 

99.3 

100.3 

110.8 
108.4 

123.7 
113.0 


Kilos 


Height 


3.43 
3.26 

7.26 
7.03 

9.29 
8.84 

10.35 
9.98 

12.02 
11.56 

14.14 
13.60 

15.87 
15.41 

18.71 
18.06 

20.48 
19.87 

22.44 
21.78 

24.70 
24.01 

26.58 
26.10 

30.22 
29.07 

32.83 
31.87 

36.21 
36.90 

40.04 
41.36 

45.03 
45.50 

50.26 
49.17 

56.09 

51.24 


Indies 

20.6 
20.5 

25.4 
25.0 

29.0 
28.7 

30.0 
29.7 

32.5 
32.5 

35.0 
35.0 

38.0 
38.0 

41.7 
41.4 

44.1 
43.6 

46.2 
45.9 

48.2 
48.0 

50.1 
49.6 

52.2 
51.8 

54.0 
53.8 

55.8 
57.1 

58.2 
58.7 

61.0 
60.3 

63.0 
61.4 

65.6 
61.7 


i  in  -i 


Cm. 

52.5 
52.2 

■  64.8 
63.6 

73.8 
73.2 

76.3 
75.6 

82.8 
82.8 

89.1 
89.1 

96.7 
96.7 

106.0 
105.3 

112.0 
110.9 

117.4 
116.7 

122.3 
122.1 

127.2 
126.0 

132.6 
131.5 

137.2 
136.6 

141.7 
145.2 

147.7 
149.2 

155.1 
153.2 

159.9 

155.9 

166.5 
156.7 


Inches 


13.4 
13.0 

16.5 
16.1 

18.0 

17.4 

18.5 
18.0 

19.0 

18.5 

20.1 
19.8 

20.7 
20.5 

21.5 
21.0 

23.2 

22.8 

23.7 
23.3 

24.4 
23.8 

25.1 
24.5 

25.8 
24.7 

26.4 
25.8 

27.0 
26.8 

27.7 
28.0 

28.8 
29.2 

30.0 
30.3 

31.2 

30.8 


Cm. 


Head 


34.2 
33.2 

42.0 
41.0 

45.9 
44.4 

47.1 
45.9 

48.4 
47.0 

51.1 
50.5 

52.8 
52.2 

54.8 
53.5 

59.1 
58.3 

60.6 
59.5 

62.2 
60.8 

63.9 
62.5 

65.6 
63.0 

67.2 
65.8 

68.8 
68.3 

70.6 
71.3 

73.3 

74.1 

76.6 
76.8 

79.2 
78.8 


Inches        Cm 


13.9 
13.5 

17.0 
16.6 

18.0 
17.6 

18.5 
18.0 

18.9 
18.6 

19.3 
19.0 

19.7 
19.5 

20.5 

20.2 


21.0 
20.7 


21.8 

21.5 


46  NOEMAL    GEOWTH   AND    DEVELOPMENT 

second  six  months  2.4  centimetres  (1  inch)  ;  during  the  second  year, 
2.3  centimetres  (nearly  1  inch),  and  less  than  1  centimetre  (V3  inch) 
the  third  year.  By  the  seventh  year  the  head  has  attained  nearly  its 
full  development.  The  growth  is  most  noticeable  in  the  anteroposterior 
diameter. 

This  rapid  growth  of  the  head  during  the  first  six  months  apparently 
increases  the  anterior  fontanelle  which,  however,  diminishes  in  size 
towards  the  end  of  the  first  year  and  is  ordinarily  completely  ossified 
by  the  middle  of  the  second  year.  The  sutures  show  the  beginning  of 
firm  union  about  the  ninth  month.  Differentiation  between  the  outer 
and  inner  tables  of  the  skull  with  the  formation  of  the  diploe  proceeds 
gradually.  Bony  deposition  in  the  vitreous  table  deepens  the  outlines 
of  the  great  venous  sinuses.  The  mastoid  process  becomes  distinct  after 
the  first  year.  From  infancy  to  puberty  there  is  a  continuous  formation 
of  new  bone  from  the  periosteum  on  the  surface  of  the  mastoid  portion 
of  the  temple  bone.  This  process  consists  of  cancellous  tissue,  and  can  be 
readily  penetrated  by  the  knife  in  operations  for  mastoiditis.  Towards 
puberty,  rarely  earlier,  the  process  becomes  hollowed  into  air-cells.  The 
cells  are  lined  with  a  delicate  mucous  membrane  and  communicate  with 
the  antrum  and  with  one  another.  They  vary  in  size  in  different  bodies 
and  on  the  two  sides  of  the  same  head.  The  proximity  of  the  lateral  sinus 
renders  it  liable  to  become  involved  by  extension  of  inflammation  in  sup- 
purative disease  of  the  mastoid  cells,  owing  to  the  thinness  of  the  bony 
septa  between  the  cells  and  the  sinus. 

As  the  mastoid  increases  in  thickness,  the  antrum  comes  to  lie  at  a 
greater  depth  from  the  surface  and  becomes  relatively  smaller. 

The  bony  ring,  which  represents  nearly  all  of  the  osseous  portion  of 
the  external  auditory  meatus  at  birth,  has  grown  outwards  to  form  the 
walls  and  the  floor.  The  Eivinian  notch  generally  persists  until  puberty, 
and  is  not  infrequently  found  in  the  adult. 

It  is  calculated  that  in  the  adult  the  osseous  portion  forms  two-thirds 
of  the  total  length  of  the  meatus.  At  the  end  of  the  first  year,  only 
the  inner  third  has  bony  walls,  and  even  in  a  child  of  six  years,  scarcely 
half  is  osseous.  A  knowledge  of  the  length  of  the  external  auditory 
meatus  at  different  ages  is  obviously  important  (Fig.  34).  The  follow- 
ing from  Symington  shows  this,  also  the  difference  in  length  of  the  floor 
and  roof  of  the  meatus. 


Agb  of  Child 

Length  of  Floor 

Length  of  Roof 

Two  months 
Six  months 
Two  years 

17  Mm. 
19  Mm. 
22  Mm. 

13  Mm. 
16  Mm. 
16  Mm. 

The  only  important  change  in  the  tympanum  is  the  obliteration  of 
the  petrosquamous  suture  which  often  occurs  by  the  end  of  the  first 
year. 


BONES    OF    HEAD    AND    FACE 


47 


The  Eustachian  tube  doubles  its  length  between  infancy  and  maturity, 
the  growth  being  especially  rapid  during  the  first  few  years,  so  that  by 
the  fifth  or  sixth  year,  its  length  is  not  far  from  that  of  the  adult.  The 
growth  seems  to  occur  mainly  in  its  anterior  or  pharyngeal  portion. 
The  tube  changes  its  almost  horizontal  direction  to  form  an  angle  of  at 
least  forty-five  degrees  with  the  horizon.  This  descent  of  the  tube  docs 
not  keep  pace  with  that  of  the  nasal  floor.  At  birth  it  is  found  at  the 
level  of  the  hard  palate,  while  at  the  age  of  four  years  it  is  three  or 
four  millimetres  above,  and  in  the  adult  ten  millimetres  above. 

Unlike  that  of  the  head,  the  growth  of  the  face  is  a  gradual  process, 


Poll.  Perforated  Spot 


Fig.  34.— Coronal  section  of  head  at  plan 


mditory  meati.    Girl  of  5  years.     (Symington.) 


going  on  steadily  from  birth  to  adult  life.  The  small  size  may  be  at- 
tributed to  the  rudimentary  condition  of  the  teeth  and  the  smallness  of 
the  maxillary  sinuses. 

Ankylosis  of  the  frontal  bones  begins  early,  and  there  may  be  no 
trace  of  the  suture  in  the  adult  skull.  The  frontal  sinuses  appear  about 
the  seventh  year.  The  ethmoidal  cells  appear  at  the  third  year.  The 
communication  through  the  foramen  caecum  is  closed  about  puberty. 

The  septum  of  the  nose  is  usually  straight  up  to  the  seventh  year; 
after  which  it  very  commonly  inclines  to  one  side.  The  nasal  sinuses 
increase  in  height  simultaneously  with  the  lengthening  of  the  vertical 
plates  of  the  palate  bones  (Fig.  35). 

During  the  first  year  the  two  halves  of  the  inferior  maxilla  ankylose, 
union  taking  place  from  below  upwards,  but  is  not  complete  until  the 
second  year. 


48 


NORMAL    GROWTH    AND    DEVELOPMENT 


NASOPHARYNX. 

As  mentioned  previously,  the  nasopharynx  is  richly  supplied  with 
lymphoid  tissue.  There  is  an  aggregation  of  follicles  in  the  posterior 
wall  known  as  the  third,  pharyngeal,  or  Luschka's  tonsil. 

The  different  findings  of  surgical  anatomists  in  respect  to  this  area 
may  well  raise  the  question  whether  Luschka's  tonsil  is  a  normal  ana- 
tomical entity.  The  rapid  growth  which  this  mass  of  lymphoid  tissue 
frequently  takes  on  in  early  years  makes  it  of  pathological  interest. 

From  the  lengthening:  of  the  face,  the  increasing  distance  between 


Lacrymal  Gland 1 

OfcH.-uus  Superior n 

tihraoidal  Sinus. n 

Restue  Inferior. I 

lnfundibulurn J) 

Antrum  of  H;ghmore._J 
8ocket  fcr  Ferm.  Canin2. 

2nd  Bicuspid S 


'Mm 


I Obliquus  Inferior. 


2nd  Temp.  Mniar       *S 


Subl'">gM 


G/ani 


Fig.  35. — Coronal  section  of  head.    Girl  of  5  years.    (Symington.) 

the  pterygoid  plates,  the  diminishing  obliquity  of  the  vomer,  and  the 
subsidence  of  the  soft  palate  which  becomes  more  vertical,  the  vault  of 
the  pharynx  becomes  more  capacious  (Fig.  35). 

The  posterior  nasal  openings,  extremely  small  in  infancy,  develop 
irregularly.  It  is  stated  that  their  size  is  doubled  in  the  first  six  months, 
then  remaining  stationary  to  the  end  of  the  second  year,  they  again  pass 
through  a  period  of  increased  growth.  The  subsidence  of  the  hard  palate 
increases  the  capacity  of  the  nasal  respiratory  tract,  principally  in  the 
height  of  its  inferior  meati,  the  middle  portions  being  wider  than  the 
openings, — a  point  to  be  remembered  in  the  lodgement  of  foreign  bodies. 

The  antrum  of  Highmore,  although  small,  is  from  birth  lined  with  a 
mucous  membrane  which  may  become  the  seat  of  infection. 

As  before  stated  the  frontal  sinuses  assume  their  relationship  to  the 
respiratory  tract  about  the  seventh  year. 


Sup.  Longitudinal  Slnua 
Inf.  Longitudinal  8inua- 

"aim  of  Qali 
f«l>  MaJ 

Straight  8 


Fall  Minor 

Medulla 


Lymphatic  GlandB. 
Right  Pulmonary  Artery 


<..;'.■      ...Right  Ventricle. 

Mi,    J.  7th  Right  Coital  OartUaga. 

A  Ensiform  Curtilage. 


Lobului  Spigelii. 
12th  Dona  I  V 

aorta.^   k; 
Suoerio'  Meaenteno  Vem. 

3rd  part  of  Duodenum. 


fllgmoio  Flenure 


Rccto.-Ve>lcal  Pouch.  I 
Prostate. 


Symphyela  Publa 


Fig.  36.— Vertical  mesial  section.    Boy  of  6  years.    (Symington. ) 


DENTITION  49 

DENTITION'. 

The  development  of  the  temporary  teeth  begins  with  the  first  forma- 
tion of  the  jaws,  about  the  sixth  week  of  intrauterine  life.  Briefly  stated, 
they  are  simply  calcified  mucous  membrane.  At  tin-  time  of  birth  the 
crowns  of  all  the  temporary  incisors  and  canines  are  fairly  advanced 
in  calcification  (Fig.  12),  but  it  is  not  until  about  the  age  of  four  and 
one-half  years  that  the  milk-teeth  are  fully  formed.  Separated  cusps 
of  the  temporary  molars  have  also  blended  at  birth,  and  calcification  of 
the  first  permanent  molars  is  just  beginning  in  the  form  of  a  separate 
cap  for  each  cusp.  These  do  not  fuse  until  six  months  after  birth.  Dis- 
section shows  the  germs  of  the  permanent  incisors  and  canines  posterior 
and  external  to  the  corresponding  milk-teeth;  but  there  are  no  traces 
of  the  bicuspids  or  second  permanent  molars.  These  appear  between 
the  fourth  and  sixth  months  of  life. 

The  temporary  teeth  are  distinguished  from  the  permanent  by  the 
marked  bulging  of  the  crown  close  to  the  neck,  so  that  the  latter  shows 
a  well-marked  constriction.  They  are  of  smaller  dimensions,  especially 
the  canines.  The  temporary  molars  are  larger  than  the  bicuspids  which 
succeed  them.    The  roots  are  smaller  and  more  divergent. 

"With  the  completion  of  the  crown  and  beginning  of  calcification  of 
the  root,  the  process  of  eruption  commences.  The  growth  of  the  root 
propels  the  crown  towards  the  surface  of  the  gum,  the  superimposed 
tissue  disappearing  by  absorption.  Synchronously  with  the  development 
of  the  root,  the  jaw  increases  in  depth  by  the  addition  of  new  osseous 
material.  The  bony  crypt  is  rebuilt  around  the  neck  of  the  tooth  and 
forms  the  alveolus  of  the  milk-tooth. 

The  eruption  of  the  teeth  is  not  a  gradual  and  continuous  process, 
but  it  occurs  in  groups,  with  intervals  of  repose  between  the  successive 
groups.  The  lower  central  incisors  appear  from  the  sixth  to  the  ninth 
month,  their  eruption  being  completed  in  about  ten  days.  Then 
follows  a  resting  period  of  two  or  three  months,  after  which  the  upper 
incisors  appear,  both  central  and  lateral.  After  a  rest  of  a  few 
months,  come  the  lower  lateral  incisors  and  first  molars ;  four  or  five 
months  later  the  canines,  and,  finally,  about  the  second  year,  the  second 
molars  arrive. 

Order  of  Eruption  of  the  Temporary  Teeth. 

Lower  central   incisors .6th  to   9th   month. 

Upper    incisors    > 8th  to   10th  month. 

Lower  lateral  incisors  and  first  molars 15th  to  21st  month. 

Canines    16th  to  20th  month. 

Second    molars    20th  to  30th  month. 

Scarcely  a  year  elapses  after  calcification  of  the  milk  teeth  is  com- 
plete before  absorption  begins.  There  is  still  much  to  learn  of  the  cause 
of  this  absorption,  as  it  seems  to  be  quite  independent  of  the  presence 
and  pressure  of  the  permanent  set.  Normally,  absorption  begins  at  the 
apex  of  the  root  and  advances  towards  the  crown.    Shortlv  after  the  root 

4 


50 


NORMAL    GROWTH    AND    DEVELOPMENT 


has  disappeared  the  crown  is  removed  either  by  the  advancing  permanent 
tooth  or  by  an  accidental  rupture  of  the  attachment  between  the  neck  of 
the  tooth  and  the  mucous  membrane  of  the  gum. 

As  mentioned,  the  calcification  of  the  permanent  teeth  begins  before 
birth.  The  process  extends  to  about  the  twelfth  year.  Just  before  the 
shedding  of  the  temporary  teeth — i.e.,  about  the  sixth  year — there  are 
more  teeth  in  the  jaw  than  at  any  other  time  of  life  (Fig.  37).  There 
are  present  all  the  temporary  teeth  and  the  crowns  of  all  the  permanent 
set,  excepting  the  wisdom  teeth, — in  all  forty-eight. 

The  permanent  teeth  may  be  divided  into  two  sets, — the  ten  anterior, 
which  succeed  the  milk-teeth,  and  six  others  that  are  superadded  farther 


Fig.  37. — Dissection  showing  number  of  teeth  at  sixth  year.     (Talbot.) 

back  in  the  jaw.  They  arise  from  successive  extensions  of  the  common 
dental  laminae  carried  backwards.  During  the  growth  of  the  teeth  the 
jaw  increases  in  depth  and  length  and  undergoes  changes  in  form 
(Fig.  38). 

The  space  taken  up  by  the  ten  anterior  permanent  teeth  very  nearly 
corresponds  with  that  which  has  been  occupied  by  the  ten  milk-teeth; 
the  difference  in  width  between  the  incisors  of  the  two  sets  being  com- 
pensated for  by  the  smallness  of  the  bicuspids  in  comparison  with  the 
milk  molars  which  they  succeed. 

The  room  necessary  for  the  accommodation  of  the  three  permanent 
molars  in  the  alveolar  arch  is  obtained  by  absorption  of  the  anterior 
part  of  the  coronoid  process.  This  absorption  is  accompanied  by  a  new 
formation  of  bone  at  the  posterior  part  of  the  ascending  ramus.  This 
gradual  remodelling  of  the  bone  is  naturally  a  slow  process.  At  certain 
periods  in  the  growth  there  is  not  sufficient  room  in  the  alveolar  arch 
for  the  growing  sacs  of  the  permanent  molars ;  hence  the  latter  are  found 
enclosed  in  the  bases  of  the  coronoid  processes  of  the  lower  jaw,  and  in 


i    \. 


•%.. 


.<** 


.•^ 


y     *. 


THORAX  51 

the  maxillary  tuberosities  of  the  upper,  but  they  afterwards  assume  their 
ultimate  position  as  the  bones  increase  in  length. 

As  the  permanent  teeth  erupt,  the  sockets  of  the  temporary  teeth  dis- 
appear by  absorption  and  new  alveoli  are  built  for  the  second  set. 

Order  of  Eruption  of  Permanent  Teeth. 

First   molars 6th    year. 

Central    incisors 7th   year. 

Lateral    incisors 8th    year. 

First   bicuspids 10th   year. 

{Second    bicuspids 1 1th    year. 

Canines 12th  to    13th  year. 

Second  molars 12th  to   15th  year. 

Third  molars 17th  to  21st  year. 

The  lower  teeth  usually  precede  the  upper. 

VERTEBRAL    COLUMN. 

As  the  spine  develops  and  ossification  proceeds,  the  ligamentous  at- 
tachments become  firmer  and  the  vertebral  column  loses  some  of  the  great 
flexibility  of  early  infancy. 

The  development  of  the  curvatures,  due  in  part  to  the  superincumbent 
weight  and  in  part  to  the  action  of  the  great  muscles  attached  to  the  ver- 
tebras, may  be  rendered  abnormal  by  persistent  vicious  attitudes  or 
unusual  muscular  contractions,  resulting  in  unnatural  curves,  as  in 
kyphosis,  lordosis,  and  scoliosis.  The  maintenance  of  the  permanent  cur- 
vatures is  due  to  changes  in  the  thickness  of  the  intervertebral  substance. 
There  may  be  great  variation  in  the  time  of  ossification  of  the  vertebras. 
The  process  begins  before  birth  and  is  not  fully  completed  before  the 
thirtieth  year. 

THORAX. 

As  age  advances  the  transverse  diameter  increases  more  rapidly  than 
the  anteroposterior,  so  that  a  cross  section  of  the  thorax  from  being,  at 
birth,  nearly  circular  becomes  more  elliptical  (Fig.  39). 

The  backward  and  downward  curvature  of  the  ribs  becomes  more 
and  more  pronounced.  It  is  accompanied  by  the  subsidence  of  the  ster- 
num and  attached  costochondral  areas,  changing  the  chest  from  the 
more  or  less  cylindrical  form  of  infancy  to  the  cone  shape  of  the  adult. 
On  account  of  the  compressibility  due  to  the  predominance  of  cartilagi- 
nous tissue,  the  shape  of  the  thorax  depends  largely  upon  the  continuous 
action  of  the  muscles;  hence  the  deformities  so  frequently  observed  as 
the  result  of  retarded  bone  development. 

LUNGS. 

From  infancy  to  puberty  there  is  a  gradual  change  in  the  structure 
of  the  lung.  The  air-cells  increase  in  number  and  size,  encroaching  upon 
the  connective  tissue  and  diminishing  the  vascularity  of  the  organ.  The 
air-spaces  developed  from  the  terminal  bronchi  are  covered  with  a  con- 
tinuous layer  of  nucleated  epithelial  cells,  which,  during  the  more  ex- 


52       NORMAL  GROWTH  AND  DEVELOPMENT 

tended  growth  of  the  alveoli  become  flattened,  lose  their  nuclei,  and  form 
thin  plates.  The  blood-vessels  become  less  tortuous  and  distensible.  The 
changes  in  the  lung  result  in  a  condensation  of  interstitial  tissue,  with 
increased  firmness  of  the  bronchioles  and  a  more  intimate  relation  to 
the  parenchyma.  The  air  capacity,  which  is  small  in  early  infancy,  in- 
creases rapidly  as  the  age  advances. 

As  the  thorax  shows  an  excess  of  growth  over  other  parts  of  the 
body,  so  the  lungs  have  an  even  greater  growth,  since  they  not  only  keep 
pace  with  the  increased  capacity  of  the  thorax,  but  finally  fill  a  portion 
of  the  space  formerly  occupied  by  the  thymus,  and  also  cover  to  a  greater 
extent  in  front  the  heart  and  great  vessels.  The  backward  curvature 
of  the  ribs,  a  feature  of  thoracic  development,  gives  additional  space 
for  the  lungs  posteriorly  on  either  side  of  the  spinal  column  (Fig.  39). 
As  in  the  adult,  the  apices  of  the  lungs  extend  two  finger-breadths  above 
the  clavicle  (Fig.  40),  and  there  is  no  constant  difference  in  the  location 
of  the  inferior  borders. 

A  marked  change  occurs  in  the  anterior  boundaries;  the  wide  angle 
between  the  anterior  lower  borders  of  the  lobes,  which  is  due  in  part  to 
the  encroachment  of  the  abdominal  viscera  and  in  part  to  the  flaring 
of  the  chondral  arch,  becomes  less  as  childhood  succeeds  infancy. 

There  is  no  difference  in  the  gross  arrangement  of  the  bronchi,  save 
that  in  the  development  of  the  thorax  the  bifurcation  of  the  trachea 
gradually  assumes  a  lower  relation  to  the  spinal  column  until  maturity, 
when  it  is  found  opposite  the  fourth  dorsal  vertebra. 

The  right  bronchus  occupies  a  more  vertical  position  than  the  left, 
a  point  of  interest,  as  it  is  more  liable  to  the  lodgement  of  foreign  bodies 
and  to  infection  from  the  larynx. 

The  descent  of  the  inferior  maxilla,  the  larynx,  and  the  upper  end 
of  the  sternum,  keep  nearly  equal  pace  during  the  developing  period 
until  the  age  of  puberty,  when  the  larynx  in  the  male  takes  on  a  remark- 
able growth,  especially  in  its  antero-posterior  dimensions,  bringing  into 
prominence  the  well-known  landmark,  the  pomum  Adami. 

In  the  adult  the  space  between  the  top  of  the  sternum  and  the  chin 
with  the  head  retracted  is  double  that  which  it  measures  when  the  head 
is  in  the  natural  position,  this  increase  occurring  mainly  between  the 
chin  and  the  cricoid  cartilage.  In  the  child,  however,  with  the  head 
similarly  placed,  the  increase  in  space  occurs  between  the  cricoid  car- 
tilage and  the  top  of  the  sternum,  because  in  the  child  the  cricoid 
cartilage  occupies  a  higher  position  in  the  neck. 

HEART. 

It  has  been  stated  that  the  heart  at  birth  is  relatively  large.  The 
capacity  of  its  two  sides  and  the  thickness  of  their  walls  are  nearly 
equal,  the  auricular  portion  being  still  comparatively  large.  During 
infancy  the  weight  of  the  heart  increases  rapidly,  its  rate  being  esti- 
mated at  eighty  per  cent.,  the  left  ventricle  showing  the  greatest  increase, 
its  wall  doubling  in  thickness  that  of  the  right  by  the  end  of  the  second 


ta    fie. 


■""WU** 


•a* 


IIKAKT 


53 


year.  From  the  third  to  the  tenth  year  the  weight  of  the  heart  seems  to 
fall  behind  in  the  general  growth  of  the  body,  showing  an  increase  of 
only  ten  per  cent.  At  the  approach  of  puberty  it  takes  on  a  remarkable 
growth,  stated  to  be  as  high  as  one  hundred  per  cent. 

The  limit  of  the  growth  of  this  organ  is  said  to  be  about  fifty  years. 

The  position  of  the  heart  in  its  relation  to  the  anterior  thoracic  wall 
has  been  a  subject  of  much  controversy;  different  observers  locating  the 
apex  beat  in  early  childhood  all  the  way  from  the  fourth  to  the  sixth 
interspace,  and  from  one  to  two  finger-breadths  on  either  side  of  the 
nipple  line. 

That  clinicians  should  differ  so  widely  in  their  conclusions  would 
suggest  either  that  hearts  vary  in  their  positions  in  different  children, 
or  are  subject  to  variations  in  the  same  individual.     It  is  more  than 


Fig.  41.— Von  Starck's  types  of  relative  and  absolute  cardiac  dulness.    Type  I,  first  year ;  Type  II, 
from  the  first  to  the  sixth  year ;  Type  III,  from  the  sixth  to  the  twelfth  year. 


probable  that  both  are  true.  It  can  be  demonstrated  that  peculiar  con- 
formations of  the  thorax  affect  the  position  of  the  apex,  as  the  crowded 
viscera  must  conform  to  their  more  rigid  surroundings. 

Again,  the  position  of  the  individual,  whether  upright  or  horizontal, 
is  known  to  change  the  position  of  the  apex  through  the  influence  of 
gravity.  So,  too,  any  crowding  from  distended  abdominal  organs  may 
lift  the  movable  apex.  In  all  probability  there  is  no  marked  change 
in  the  relative  height  of  this  organ,   though  the  more   rapid   growth 


54  NORMAL    GROWTH   AND    DEVELOPMENT 

of  chest  wall  as  compared  with  heart  growth  may  bring  the  apex  impact 
nearer  the  median  line. 

In  very  young  infants  the  exact  location  of  the  apex  is  not  always 
easy  to  determine,  owing  partly  to  the  interposition  of  adipose  and  the 
want  of  systolic  vigor.  In  early  infancy  the  relatively  large  right  ven- 
tricle, moreover,  comprises  the  entire  anterior  aspect  of  the  heart.  The 
left  ventricular  apex,  lying  posteriorly,  does  not  impinge  against  the 
chest  wall  with  the  defmiteness  of  advanced  childhood.  The  more  trans- 
verse position  of  the  heart  itself  and  the  sharper  curvature  of  the  costo- 
chondral  region,  obscures  somewhat  the  apex  behind  the  shelving  border 
of  the  left  lung,  increasing  the  indefiniteness  of  the  infantile  apex  beat. 
But  later  in  childhood  the  heart  beat  is  easily  felt  and  may  be  more 
plainly  noted  than  in  the  adult. 

As  a  rule,  the  apex  beat  is  located  beyond  the  nipple  line  in  early 
childhood,  but  in,  or  within  that  line  in  later  childhood,  and  usually  in 
the  fourth  or  fifth  interspace.  The  accompanying  diagrams  of  von 
Starck  's  ' '  Types ' '  represent,  with  a  fair  degree  of  accuracy,  the  com- 
parative areas  of  cardiac  dulness,  both  relative  and  absolute,  at  different 
ages  of  childhood  (Fig.  41).  The  larger  majority  of  observers  have 
located  the  right  border  of  the  heart  to  the  right  of  the  sternum  at  all 
periods  of  childhood. 

BLOOD-VESSELS. 

There  are  some  changes  in  the  blood-vessels  that  should  be  mentioned. 
The  relative  capacity  of  the  arteries  to  the  heart  is  greater  in  infancy 
and  childhood,  thus  rendering  the  arterial  tension  low.  The  enormous 
growth  of  the  heart  at  puberty  produces  a  marked  change  in  their 
relation. 

The  growth  of  the  arteries  is  not  uniform.  This  is  best  seen  in  the 
femoral  and  renal,  as  compared  with  the  carotid  and  pulmonary,  the 
two  latter  showing  but  little  postnatal  growth,  while  the  former  develop 
in  a  marked  degree.  This  is  a  point  of  interest,  as  it  helps  to  explain 
the  tendency  to  renal  congestion  so  noticeable  in  young  children. 

THYROID. 

As  childhood  advances,  with  the  disappearance  of  subcutaneous  fat 
and  the  sinking  of  the  manubrium  sterni,  the  thyroid  gland  becomes  more 
evident  and  can  more  easily  be  outlined.  The  fluid  contained  in  its  cells, 
which  in  the  foetus  and  new-born  is  serous  in  character,  changes  gradu- 
ally to  a  colloid  material.  Not  infrequently  the  thyroid  increases  in 
size  at  the  approach  of  puberty. 

THYMUS. 

The  thymus  increases  in  size  up  to  the  end  of  the  second  year ;  it  is 
usually  stationary  until  the  sixth  year,  after  which  it  gradually  atrophies, 
disappearing  from  the  neck  and  from  behind  the  middle  third  of  the 
sternum,  its  only  vestige  being  a  mass  of  fatty  tissue  in  the  superior 


ALIMENTARY    TRACT  55 

mediastinal  space.     The  atrophy  is  associated  with  a  closer  approxi- 
mation of  the  pleura?  and  lungs,  behind  the  sternum. 

■     ALIMENTARY    TRACT. 

Within  the  first  few  weeks  of  life  the  mucosa  of  the  mouth  loses  its 
dusky  hyperaemic  appearance,  and  at  the  same  time  the  so-called  epithelial 
pearls — small  yellowish-white  nodules  frequently  found  in  the  median 
line  of  the  hard  palate — disappear. 

The  tongue  and  buccal  surfaces  become  more  moist  with  the  in- 
creasing secretions  from  the  buccal,  labial,  and  salivary  glands. 

The  characteristic  coating  of  the  baby  tongue  persists  during  the 
greater  part  of  the  nursing  period.  The  roof  of  the  mouth  gradually 
becomes  more  arched  with  the  development  of  the  alveolar  ridges.  The 
velum  palati  becomes  ampler  as  it  descends  to  its  more  vertical  position, 
the  uvula  elongates  and  the  tonsils  increase  in  size.  The  masses  of  fat 
(sucking  pads)  found  in  the  buccal  parietes  diminish,  although  traces 
of  them  remain  in  later  life. 

Between  the  pharynx  and  the  vertebral  column  is  a  considerable 
amount  of  loose  connective  tissue,  containing  the  postpharyngeal  glands ; 
of  interest  as  they  may  be  the  seat  of  retropharyngeal  abscesses.  With 
the  body  growth  the  pharynx  and  oesophagus  lengthen,  the  latter  curving 
somewhat  as  it  follows  the  spine,  with  which  it  is  in  close  relation 
(Fig.  36). 

STOMACH. 

The  stomach  develops  rapidly,  especially  in  the  region  of  the  fundus, 
increasing  greatly  in  its  longer  curve,  the  walls  thickening  and  becoming 
more  muscular. 

The  patulous  cardiac  orifice  assumes  gradually  its  valve-like  arrange- 
ment, characteristic  of  later  life. 

The  lymphoid  tissue,  which  is  abundant  in  the  mucosa  of  the  young 
stomach,  gradually  diminishes  as  the  peptic  glands  increase  in  size  and 
activity. 

The  position  of  the  stomach,  at  first  completely  covered  in  front  by 
the  left  lobe  of  the  liver  (Fig.  25),  changes  with  its  own  rapid  growth 
so  that  by  the  sixth  month  a  portion  of  the  lower  border  presents  below 
that  organ.  After  one  year  of  age  percussion  should  outline  at  least  a 
third  of  the  normally  distended  stomach. 

A  great  deal  has  been  written  in  regard  to  the  growth  of  the  stomach 
in  infancy.  The  difficulties  in  the  way  of  measuring  the  capacity  of  this 
viscus  during  life,  and  its  distensibility  when  filled  post-mortem,  render 
unsatisfactory  all  attempts  to  determine  accurately  its  size  at  different 
periods.  Were  the  pylorus  closed  the  stomach  could  easily  be  filled  with 
a  known  quantity  of  fluid,  or,  by  weighing  before  and  after  nursing,  the 
amount  ingested  could  be  determined.  But  even  this  method  would  lack 
accuracy,  as  allowance  must  be  made  for  absorption.  As  the  result  of 
many  recent  post-mortem  examinations  and  many  weighings  before  and 


56       NORMAL  GROWTH  AND  DEVELOPMENT 

after  nursing,  some  fairly  approximate  conclusions  have  been  generally 
accepted. 

The  following  table  represents  fairly  the  average  capacity  of  the 
stomach  at  different  ages :  * 

Centimetres.  Ounces. 

At  birth 30  1 

At  end  of  first  month    75  2.\ 

At  end  of  second  month    105  3J 

At  end  of  third  month    135  4-J 

At  end  of  fourth  month    150  5 

At  end  of  fifth  month    165  o\ 

At  end  of  twelfth  month    255  %\ 

The  growth  of  the  stomach  is  most  rapid  in  the  first  half  of  the  first 
year,  of  which  the  first  three  months  exhibit  by  far  the  greater  rate  of 
increase.  By  comparing  the  above  with  the  tables  of  growth,  it  will  be 
observed  that  the  gastric  capacity  maintains  a  very  constant  ratio  of 
increase  with  that  of  body  weight  in  the  first  year  of  life. 

INTESTINES. 

Much  has  been  said  concerning  the  changes  in  the  lower  digestive 
tube  during  development.     A  few  measurements  may  be  given  here. 

Small  intestine  at  birth — 286  centimetres  (9  ft.  5  in.). 

Small  intestine  at  end  of  second  month — 296  centimetres  (9  ft.  9  in.). 

After  this  its  growth  is  very  irregular. 

Large  intestine  at  birth— 56  centimetres  (1  foot  10  inches),  of  which 
the  sigmoid  represents  25.5  centimetres  (10  inches)  and  the  imperfect 
caecum  about  5  centimetres'  (2  inches).  The  growth  is  slight,  or  even 
none,  for  the  first  four  months,  but  the  following  measurements  have 
been  verified: 

End  of  first  year    76  centimetres    (2  feet  6  inches) 

End  of  sixth  year    91.5  centimetres    (3  feet) 

End  of  thirteenth  year   106  centimetres    (3  feet  6  inches) 

In  the  progress  of  growth  differentiation  occurs  between  the  various 
portions,  as  duodenum,  small  intestine,  caecum,  colon,  and  rectum. 

That  the  growths  of  the  different  portions  of  this  tube  are  not  uni- 
form and  bear  no  constant  relation  to  the  growth  of  the  body,  would 
seem  to  explain  the  apparent  anomalies  of  position  and  dimensions 
noted  by  different  observers.  Descriptions  of  aberrant  bowels  need 
occasion  no  surprise.  The  colon  may  extend  directly  from  the  hepatic 
flexure  diagonally  to  the  left  iliac  region,  or  from  the  splenic  flexure  to 
the  right  iliac,  with  the  rectum  on  the  right  side  of  the  sacrum.     An 

*  Gastric  capacity  as  mentioned  above  must  not  be  confounded  with  the  amount 
of  food  an  infant  may  take,  concerning  which  reference  will  be  made  in  the  chapter 
on  foods. 


LIVKK 


57 


immense  loop  may  be  thrown  out  from  the  left  iliac-  fossa  which,  reaching 
to  the  umbilicus,  returns  to  the  rectum,  as  a  rudimentary  sigmoid. 

It  has  not  been  demonstrated  thai  the  small  intestine  follows  a  very 
definite  course,  or  bears  during  its  growth  any  constant  relationship 
to  other  viscera,  varying  little  in  form  or  structure  throughout  its  length 
until  it  joins  the  caecum,  which  in  the  earliest  infancy  shows  marked 
departure  from  the  preceding  tube.  Many  descriptions  agree  that  this 
important  organ  is  found  in  the  very  young  relatively  high  without,  how- 
ever, any  fixed  habitat  for  itself  or  its  appendix,  the  angle  at  the  ileo- 
cecal junction  maintaining  no  constant  value. 

From  this  point  on,  the  tube  assumes  the  sacculated  form  which  is 
characteristic  of  the  colon.  The  ileum  gradually  descends  to  its  perma- 
nent position  and  the  flexures  assume  their  definite  relations  to  the  liver 
and  spleen,  though  the  lower  termination  exhibits  vagaries  in  the  length 
and  position  of  that  part  known  as  the  sigmoid.  The  rectum  loses  its 
relative  redundancy  as  it  adjusts  itself  to  the  increasing  depth  and 
posterior  curvature  of  the  pelvis.  One  peculiarity  of  the  lower  digestive 
tube  in  infancy  is  the  ample  mesentery,  an  arrangement  which  allows 
adaptation  of  this  convoluted  tube  to  the  rapidly  increasing  dimensions 
of  the  abdominal  cavity. 

LIVER. 

The  increase  in  the  weight  of  the  liver  does  not  keep  pace  with  that 
of  the  body,  showing  a  tendency  to  fall  behind  throughout  life.     The 


Fig.  42 


-Horizontal  section  made  at  the  level  of  disk  between  eleventh  and  twelfth  vertebra;. 
5  years.    (Symington.) 


Bov  of 


relative  reduction  of  liver  weight  at  birth  is  not  surprising  when  the 
changes  in  blood  circulation  at  that  time  are  considered. 

The  decrease  in  area  of  liver  dulness  is  due  to  the  increasing  promi- 
nence of  the  rapidly  growing  stomach  and  the  elongation  of  the  abdomi- 
nal spine  (Fig.  42). 

The  retardation  of  growth  is  most  marked  in  the  left  lobe,  retiring 
as  it  does  from  a  point  midway  between  xiphoid  and  umbilicus  to  the 


58 


NORMAL    GROWTH   AND    DEVELOPMENT 


restricted  area  found  later  in  front  of  the  pylorus.  Advancing  childhood 
with  its  lowered  diaphragm  shows  the  superior  border  of  the  liver  one 
rib  lower  than  in  infancy. 

The  lower  margin  frequently  found  at  birth  midway  between  costal 
margin  and  crest  of  ilium,  apparently  ascends  until  at  puberty  it  may 
correspond  with  the  lower  border  of  the  ribs. 

SPLEEN. 

The  peculiarity  of  the  spleen  in  infancy  and  childhood  is  its  ready 
tendency  to  enlargement. 

KIDNEYS. 

The  kidneys  maintain  their  lobulated  appearance  for  several  years, 
assuming  gradually  the  smooth  surface  that  is  a  characteristic  of  adult 
life. 

The  relative  slowness  of  their  growth  as  compared  with  that  of  the 
spinal  column  sufficiently  accounts  for  the  apparent  change  of  position 
of  the  superior  and  inferior  borders. 

BLADDER. 

From  the  semi-abdominal  position  at  birth,  the  bladder  sinks  down- 
ward as  the  pelvis  develops  in  depth  and  breadth.     This 'subsidence  is, 


Fig.  43.— Distended  bladder  of  an  infant  of  15  months.     (Symington.) 

no  doubt,  favored  by  the  weight  of  the  urine  and  the  assumption  of  the 
upright  position  (Fig.  36). 

Of  surgical  interest  is  the  relation  of  the  peritoneum  to  the  bladder 
at  different  periods  of  growth.  As  previously  stated,  the  extensive 
anterior  surface  of  the  bladder  at  birth  is  devoid  of  peritoneal  covering 
and  lies  in  intimate  relationship  with  the  anterior  abdominal  wall,  occu- 


Fig.  44.— Clothing  for  young  infant.    Outer  garment,  sleeveless  slip,  and  shirt. 


Fig.  45.— Same  as  Fig.  44.    Closed. 


NER VOI'S    SYSTEM  59 

pying  the  lower  two-thirds  of  the  space  between  the  symphysis  and  the 
umbilicus  (Figs.  28  and  43). 

In  contrast,  the  posterior  surface  is  invested  with  peritoneum  as  low- 
down  as  the  commencement  of  the  urethra.  In  the  growth  of  this  viscus 
the  broadening  base  is  partially  uncovered,  the  peritoneum  being  re- 
flected upon  the  rectum,  forming  the  rectovesical  fold. 

From  about  two  drachms  at  birth  to  an  ounce  at  six  months  the 
capacity  of  the  bladder  shows  great  variations  and  is  susceptible  of  great 
distention. 

UTERUS. 

The  high  position  of  the  infantile  uterus  and  ovaries  changes  with 
the  pelvic  development,  the  fundus  maintaining  its  rudimentary  form 
and  structure  until  the  approach  of  puberty,  at  which  time  differentia- 
tion from  the  cervical  portion  is  rapidly  established.  About  the  same 
time  the  vagina  assumes  a  more  horizontal  position,  which,  with  the 
increasing  anteversion  of  the  uterus,  diminishes  the  intervened  angle. 

No  marked  changes  occur  in  the  generative  organs  until  the  approach 
of  puberty. 

INGUINAL    CANAL. 

The  internal  and  external  inguinal  rings,  which  were  originally  in 
apposition,  become  separated  with  the  growth  of  the  lower  abdominal 
walls,  the  intervening  tissue  being  elongated  into  a  canal  lying  obliquely 
between  the  muscular  layers. 

NERVOUS    SYSTEM. 

By  comparing  the  weight  of  the  brain  with  that  of  the  body  at 
different  ages,  we  find  that  their  growth  follows  a  quite  similar  course 
during  the  first  year.  From  this  time  on,  the  ratio  decreases,  as  is  seen 
by  the  following  table : 


Ratio  of  Brain  to  Body   Weight 

At  birth 1  :    8 

During  first  year 1  :    0 

During  second  year 1  :  14 

During  third  year 1:18 


f  1  •  15 
During  fourteenth  year J.  ,  \  n- 

Adult 1  :43 


The  entire  brain  substance  attains  nearly  its  adult  size  by  the  seventh 
year.  Owing  to  the  large  size  at  birth,  the  growth  of  the  brain  en  masse 
is  not  remarkable,  but  the  alteration  in  its  consistency,  the  increasing 
differentiation  of  its  gray  and  white  substances,  the  deepening  of  the 
fissures  and  sulci,  and  the  increasing  complexity  of  the  convolutions,  all 
show  the  occurrence  of  a  marked  progressive  change  (Figs.  34  to  36). 

The  most  rapid  growth  of  the  cerebrum  is  seen  in  the  frontal  lobes, 
altering  the  position  and  direction  of  the  fissures  of  Sylvius  and 
Rolando. 

Cellular  multiplication  in  the  cortex  is  said  to  cease  in  the  human 
being  at  the  third  month  of  fetal  life.  Although  all  the  cells  may  be 
present  at  birth,  they  are  in  a  very  rudimentary  state  and  may  require 


60  GROWTH    AND    DEVELOPMENT 

years  for  growth  before  they  attain  the  condition  necessary  for  perfec- 
tion of  function.  The  term  elaboration  has  been  used  to  describe  the 
change  from  the  simple  cell  of  the  new-born,  with  its  large  nucleus  and 
small  amount  of  protoplasm,  to  the  highly  complex  type  of  the  adult. 
Out  of  the  great  number  of  cells  present  at  birth,  a  considerable  part 
are,  probably,  never  highly  developed  even  in  the  brains  of  those  well 
educated  and  skilfully  trained. 

In  the  adult  the  medullary  substance  has  been  estimated  at  about 
thirty  per  cent,  of  the  entire  weight  of  nerve  tissue.  The  highest  rate 
of  development  throughout  infancy  and  early  childhood  occurs  in  the 
medullary  portion.  In  very  early  infancy  the  peripheral  nerves  have 
sheaths  of  myeline,  which  later  may  be  traced  in  the  spinal  cord,  medulla 
oblongata,  and  finally  to  the  cerebrum.  The  extent  of  medullation  of 
any  tract  is  an  index  of  the  degree  of  development  of  that  tract. 

In  the  same  way  may  be  traced  the  earlier  development  of  those 
nerve  areas  which  control  merely  bodily  functions  and  reflexes.  The 
higher  intellectual  functions  show  evidence  of  their  activity  later, 
although  ultimately  they  monopolize  the  greater  portion  of  the  cortex. 

The  weight  of  the  spinal  cord  to  body  weight  at  birth  is  1 :  500 ;  in 
adult  life,  1 :  1500.  In  its  longitudinal  growth  the  spinal  cord  does  not 
keep  pace  with  that  of  its  canal  (Fig.  36).  It  is  due  to  this*  relative 
shortening  of  the  cord  that  the  roots  of  the  lower  spinal  nerves  assume 
an  increasingly  higher  relationship  to  the  respective  segments  from 
whose  foramina  they  emerge  (a  point  of  diagnostic  and  surgical  inter- 
est). It  will  be  remembered  also  in  this  connection  that  the  tips  of  the 
spinous  processes  vary  considerably  at  different  ages  in  their  relations 
to  their  respective  vertebrae 


CHAPTER    III 

PHYSIOLOGY    AND    HYGIENE    OF    THE    NEW-BORN 

CIRCULATION    OF    THE    BLOOD 

The  most  noticeable  physiological  processes  in  the  very  young  infant 
are  respiration  and  circulation.  The  latter,  having  begun  during  pre- 
natal existence,  seems  to  be  better  established. 

It  is  asserted  that,  at  the  instant  of  birth,  the  heart's  action  is  sus- 
pended, to  be  resumed  a  fraction  of  a  moment  later.  Be  that  as  it  may, 
it  is  quite  evident  that  the  radical  change  in  the  plan  of  circulation 
produces  a  disturbance  of  equilibrium,  resulting  in  a  marked  increase 
of  blood  pressure  in  some  vessels  with  corresponding  diminution  in 
others. 

The  diminished  pressure  in  the  right  auricle,  upon  the  ligation  of 
the  umbilical  vein,  tends  to  reduce  the  blood  flow  through  the  foramen 
ovale.  Diminished  pressure  in  the  right  ventricle  encourages  blood  flow 
through  the  tricuspid  opening.  The  increased  afflux  of  blood  to  the  lungs 
diminishes  the  current  through  the  ductus  arteriosus.  The  inflation  and 
sudden  congestion  of  the  lungs,  increasing  the  interthoracic  pressure,  is 
claimed  to  exert  a  special  influence  on  the  vessels  at  the  base  of  the  heart, 
favoring  the  occlusion  of  the  ductus  arteriosus.  The  early  return  of  the 
pulmonic  circulation,  increasing  the  pressure  in  the  left  auricle,  still 
further  checks  the  tendency  of  the  current  through  the  foramen  ovale 
and  favors  its  early  closure.  It  also  increases  the  pressure  in  the  left 
ventricle,  which  now  sustains,  for  the  first  time,  the  burden  of  circula- 
tion, with  resulting  rapid  growth  in  the  thickness  of  its  walls. 

The  heart,  undoubtedly,  has  imposed  upon  it  increased  labor  in  the 
new  arrangement,  which  probably  accounts  for  the  slowing  of  its  action 
noted  by  some  observers. 

Shortly  after  birth  the  pulse-rate  may  vary  from  120  to  140  per 
minute,  although  the  disturbance  of  rate  from  slight  causes  allows  con- 
siderable latitude. 

The  arterial  tension  is  low  in  early  infancy,  owing  partly  to  the 
large  size  of  the  vessels  relative  to  the  heart,  and  partly  to  their  great 
distensibility.  Before  the  age  of  six  months  the  pulse  is  not  always  easily 
counted  at  the  wrist.  The  child's  position  has  littte  or  no  effect  on  the 
rapidity  of  the  heart's  action.  It  is  usually  less  frequent  during  sleep, 
although  at  the  same  time  less  regular. 

The  rhythm,  like  the  rate  of  the  heart's  action,  is  subject  to  great 
variation  even  in  health. 

Physiologists  have  held  that  the  infant  at  birth  has  relatively  less 

6i 


62     PHYSIOLOGY   AND    HYGIENE    OF    THE    NEW-BORN 

blood  than  has  the  adult,  the  ratio  to  body  weight  being  1  :  15,  against 
1 :  13.  The  importance  of  a  few  grammes  of  blood,  more  or  less,  to  the 
very  young  infant  has  only  recently  been  fully  appreciated.  It  has  long 
been  recognized  clinically  that  babies  bear  a  loss  of  blood  poorly,  but  the 
importance  of  saving,  at  the  time  of  birth,  some  of  the  maternal  blood 
that  is  lost  with  the  placenta  has  recently  attracted  attention. 

The  practice  of  waiting  before  severing  the  cord  until  all  pulsation 
has  ceased,  has  been  improved  upon,  it  is  claimed,  and  some  accoucheurs 
strip  the  cord  towards  the  umbilicus,  thus  forcing  its  contained  blood 
into  the  vessels  of  the  infant  before  ligation.  It  is  asserted  that  this 
procedure  produces  results  in  the  early  nutrition  which  are  susceptible 
of  clinical  demonstration. 

BLOOD. 

During  the  first  few  days  after  birth  the  infant's  blood  shows  great 
variations  in  the  size  and  shape  of  the  cells  as  if  the  type  were  not  yet 
quite  fixed.  The  majority  of  observers  also  find  a  few  normoblasts  at 
this  time.  These  are  not  invariably  present,  doubtless  because  in  some 
children  the  blood  at  the  time  of  birth  is  more  developed  than  in  others. 
The  hemoglobin  at  birth  and  during  the  early  weeks  is  relatively  high 
(116  to  119  per  cent.).  The  high  percentage  is  due  not  only  to  a  poly- 
cythemia but  to  a  genuine  increase  of  hemoglobin  in  the  individual  cells. 

The  following  table  (Cabot)  of  the  blood  of  the  new-born  shows  a 
marked  leucocytosis : 


Age 

Red  Cells 

Leucocytes 

At  birth 

5,900,000 

17,000-21,000 

After  first  feeding 

26,000-36,000 
24,000 

End  of  first  day 

7,000,666-8, 8ob,666 

6,500,000 
6,000,000 
5,000,000 

End  of  second  dav 

30,000 

End  of  fourth  dav   

20,000 

End  of  seventh  day 

15,000 

This  high  increase  is  explained  by  some  as  a  combination  of  blood 
concentration  with  a  large  digestion-leucocytosis.  Of  the  white  cells 
there  is  a  relative  increase  in  the  lymphocytes  in  healthy  infants.  It  is 
stated  that  the  amount  of  fibrinogen  is  small,  and  that  the  blood  of 
this  period  coagulates  slowly.  This  is  of  interest  in  relation  to  hemor- 
rhages in  the  new-born. 

During  the  first  few  weeks  the  characteristics  of  the  blood  of  the 
new-born — viz.,  the  increase  in  number  and  varying  size  and  shape  of 
the  red  corpuscles,  the  great  increase  in  the  white,  especially  of  the 
lymphocytes,  the  high  percentage  of  hemoglobin  and  the  high  specific 
gravity — all  gradually  disappear.  In  examining  the  blood  of  an  infant 
we  should  remember  that  the  question  of  a  normal  condition  of  the 
blood  must  depend  upon  the  backwardness  or  forwardness  of  the  infant 's 
development.     After  the  first  few  weeks  the  hemoglobin  and  specific 


RESPIRATION  63 

gravity  sink  to  a  lower  level  than  in  the  adult,  the  percentage  of  haemo- 
globin reaching  as  low,  even,  as  sixty  per  cent.  It  is  suggested  that  the 
eosinophilia  usually  present  may  be  connected  with  the  great  activity  in 
bone  growth.  The  marked  diminution  of  corpuscular  elements,  haemo- 
globin, and  specific  gravity,  after  the  first  week,  is  presumably  due  to 
the  increased  metabolism  incident  to  rapid  tissue  formation. 

That  the  growth  of  different  organs  and  increase  of  function  is  in 
direct  ratio  to  the  blood  supply,  is  demonstrated  in  the  brain,  which  re- 
ceives its  blood  directly  from  the  aortic  arch  through  the  great  vessels  of 
the  neck,  its  relation  to  the  left  heart  being  the  most  intimate.  The  same 
principle  is  true  of  the  lungs.  The  liver,  being  supplied  through  the  great 
portal  vein,  securing,  it  is  claimed,  one-seventh  of  the  entire  blood,  would 
also  illustrate  this  point.  The  rapid  development  of  the  lower  extremi- 
ties keeps  pace  with  the  marked  increase  in  size  of  the  femoral  vessels. 
So,  too,  as  was  mentioned  in  a  preceding  chapter,  the  long  bones  show 
complete  ossification  earlier  at  the  extremities  towards  which  the  nutrient 
arteries  are  directed. 

Since  the  blood  supply  not  infrequently  depends  upon  the  muscular 
activity  of  the  part,  the  deduction  is  plain  that  restrained  activity  or 
interference  by  any  means  retards  both  function  and  growth.  In  the 
care  of  the  young  infant  too  much  stress  cannot  be  laid  upon  the  im- 
portance of  unrestrained  freedom  of  motion  for  all  the  members,  and 
avoidance  of  anything  that  tends  to  compress  the  vessels,  such  as  long 
continued  recumbency  in  one  position,  with  possibly  the  addition  of 
hypostasis  in  the  dependent  parts.  In  this  respect,  also,  the  clothing 
demands  attention,  that  no  bands  or  seams  press  upon  the  vessels  and 
cause  local  deficiency  or  congestion. 

RESPIRATION. 

If  any  vital  process  is  pre-eminent  in  its  importance,  it  is  that  of 
respiration.  It  has  been  demonstrated  that  young  infants  inhale  more 
oxygen  and  exhale  more  carbon  dioxide,  relatively,  than  do  adults.  This 
is  a  result,  no  doubt,  of  the  more  rapid  tissue  change  in  the  growing 
organism.  It  is  claimed,  however,  that  when  completely  deprived  of 
air,  life  is  sustained  for  a  longer  period  by  the  very  young  infant.  This 
should  be  remembered  in  efforts  at  resuscitation  of  the  asphyxiated  in- 
fant. 

Respiration,  beginning  with  postnatal  life,  is  probably  the  least 
developed  of  the  vital  functions.  Its  want  of  vigor  is  partly  due  to 
the  compressibility  of  the  chest  walls,  to  the  lack  of  full  development 
of  the  respiratory  muscles,  the  yielding  character  of  their  points  of 
origin  and  insertion,  and  partly  to  the  narrowness  of  the  upper  air- 
passages.  Added  to  these  there  are  the  enormous  thymus,  obtruding  liver, 
and  frequent  abdominal  flatus  restricting  respiratory  movement.  Fortu- 
nately for  the  young  infant  its  respiratory  process  has  no  fixed  type. 
It  may  be  partly  thoracic  or  unilateral,  but  generally  it  is  abdominal, 
adjusting  itself  to  the  ever-varying  conditions  of  environment.     Hence 


64      PHYSIOLOGY    AND    HYGIENE    OF    THE    NEW-BORN 

it  is  not  strange  that  the  rate  and  rhythm  of  respiratory  movements  are, 
in  infancy,  extremely  variable.  The  average  of  many  observations  gives 
the  rate  from  thirty  to  sixty  per  minute.  A  healthy  infant  may  sigh, 
hiccough,  or  exhibit  Cheyne-Stokes  type  of  respiration,  without  evidence 
of  any  serious  abnormality. 

Inspiration  is  accomplished  partly  by  the  contraction  of  the  muscles 
attached  to  the  ribs,  but  principally  by  the  contraction  of  the  powerful 
muscular  portion  of  the  diaphragm,  which,  lengthening  the'  vertical 
diameter  of  the  thorax,  causes  the  air  to  enter  the  glottis  by  atmospheric 
pressure.  Expiration  is  due  to  the  resiliency  of  the  diaphragm,  thoracic 
walls,  and  lung  tissue,  as  they  resume  their  former  position. 

The  ratio  of  respiration  to  pulse  in  the  very  young  infant  is  so  incon- 
stant that  it  is  of  little  value.  The  yielding  character  of  the  thorax,  as 
well  as  the  undeveloped  state  of  its  muscles,  renders  him  very  susceptible 
to  disturbances  by  compression,  so  that  great  care  should  be  exercised, 
not  only  in  the  handling  of  the  infant,  but  also  in  the  clothing,  that  no 
constriction  of  the  chest  occur.  So,  also,  care  of  the  nasal  and  pharyngeal 
tracts  is  necessary  that  no  accumulations  or  growths  interfere  with  the 
free  access  of  air. 

TEMPERATURE. 

The  temperature  in  early  infancy  does  not  exhibit  that  stability 
which  is  seen  in  later  life,  apparently  trifling  causes  producing  great 
variations.  The  rectal  temperature  of  the  new-born  is  from  99°  to  100° 
F.  (37.2°-37.8°  C).  Within  the  first  hour  it  falls  two  or  three  degrees 
and  fluctuates  without  apparent  reason  for  a  few  days,  with  a  general 
average  of  98°  F.  (36.6  C).  At  the  end  of  the  first  week  it  is  about  99° 
F.  (37.2°  C),  which  may  be  taken  as  the  average  normal  during  early 
infancy. 

The  variability  of  temperature  in  infants  is  not  surprising  when  we 
consider  the  conditions, — viz.,  the  relatively  great  radiating  surface  of 
the  body,  the  dilatability  of  the  superficial  capillaries,  and  the  thinness 
of  their  investments;  also  the  undeveloped  state  of  the  heat  regulating 
centres. 

In  infancy,  as  in  later  life,  the  temperature  shows  a  cycle  of  diurnal 
oscillations  which  corresponds  with  observations  in  regard  to  the  daily 
variation  in  the  heart's  action  and  the  older  idea  of  fluctuation  of  the 
vital  force.  Most  observers  have  found  the  temperature  to  be  the  highest 
in  the  afternoon  and  the  lowest  from  twelve  to  four  in  the  early  morning. 
Rectal  temperature  only  is  reliable,  as  in  the  young  infant  the  mouth 
cannot  be  utilized  for  that  purpose,  and  the  surface  of  the  body,  for 
reasons  before  stated,  shows  a  temperature  two  or  three  degrees  lower 
than  that  of  the  blood. 

In  view  of  the  above-mentioned  facts  it  would  seem  hardly  necessary 
to  warn  the  accoucheur  against  undue  exposure  of  the  new-born  to 
influences  which  lower  the  temperature.  Still,  the  practice  of  chilling 
the  infant  by  unnecessary  exposure,  even  to  the  extent  of  subjecting  him 


CLOTH  I. \(.; 


65 


lo  the  tub  bath,  is  so  common  that  it  cannot  be  too  emphatically  de- 
nounced. A  thorough  application  of  warm  oil  to  the  surface,  and  the 
envelopment  of  the  entire  body  in  warmed  material,  as  sofl  wool,  is  more 

ra1  ional. 

Keeping  in  mind  the  intrauterine  temperature  from  which  the 
new-comer  has  emerged,  the  intelligent  accoucheur  will  not  negled  that 
of  the  lying-in  room.  The  transition  from  99°  to  75°  p.  (37.2°-23.9  I '.  * 
is  certainly  radical  enough  for  stimulation  of  the  respiratory  and  cir- 
culatory functions. 

In  his  subsequent  care  it  must  never  be  forgotten  that  uniformity 
of  the  surrounding  temperature  should  be  maintained  and  the  child 
protected  by  clothing  from  excessive  radiation.  Nothing  is  more  appro- 
priate for  this  purpose  than  wool,  and  as  lightness  is  a  desideratum,  two 
thicknesses,  or  even  three  when  necessary,  are  better  than  one  containing 
the  same  amount  of  ma- 
terial. As  before  stated, 
clothing  must  not  be  al- 
lowed to  interfere  with 
freedom  of  muscular  move- 
ment or  of  bibod  circula- 
tion. The  evils  of  the 
pinning  blanket,  the  re- 
straining diaper,  the  tight 
abdominal  and  thoracic 
bands,  of  the  padded, 
closely  enveloping  wrap, 
the  constricting  sleeves, 
tapes,  and  strings,  are  too 
apparent  to  require  pro- 
longed criticism.  The  load- 
ing of  the  garments  with 
embroideries,  laces,  and 
useless  decorations  should 
be  discouraged. 

To  secure  the  benefits  of 
clothing,  and  at  the  same 
time  freedom  from  its  in- 
jurious effects,  is  a  prob- 
lem, the  solution  of  which 
has  been  long  sought.  The 
ideal  protection  would  seem 
to   be   afforded    by   a  large 

blanket  of  light,  flexible,  nonconducting  material,  but  this  normal  rest- 
lessness makes  it  difficult  to  keep  the  infant  within  its  folds.  A  more 
definite  garment,  that  cannot  be  thrown  off  while  still  allowing  unre- 
strained freedom  of  movement,  is  in  use  in  the  infants'  wards  of  some 
city  hospitals.     The  garment  is  a  bag  so  constructed  that  it  envelop* 

5 


Fig.  4(5.— Infant  clothed. 


66     PHYSIOLOGY   AND    HYGIENE    OF    THE    NEW-BORN 

loosely  the  entire  infant  below  the  chin,  closure  being  secured  above  by 
safety  pins,  and  below  by  a  drawstring  (Figs.  44  to  47). 

Additional  protection  against  cold  is  afforded  by  separate  under- 
garments, as  a  light  knitted  shirt,  of  silk  or  wool,  free  from  seam  or 
band,  and  one  or  more  sleeveless  slips,  as  occasion  may  require.     The 

diaper  should  be  light,  with  no  more 
material  than  is  absolutely  necessary 
for  the  absorption  of  the  discharges. 
Absorbent  cotton,  either  loose  or  in 
pads,  preferably  the  latter,  retained 
by  a  T-bandage  of  some  firm  material, 
secured  by  a  safety-pin,  has  been 
found  to  meet  all  the  requirements. 
In  exceptional  cases  some  departure 
from  the  simplicity  of  the  above  may 
be  desirable. 


ALIMENTARY    CANAL. 

The  labial  and  buccal  glands  of 
the  new-born  secrete  mucus,  which 
serves  for  protection.  'The  salivary 
secretion,  especially  in  the  parotid, 
is  established  but  feebly.  The  physi- 
ological properties  of  this  secretion 
at  birth  have  been  a  subject  of  ex- 
fig.  47.-outer  garments  removed.  tended    investigation    and    animated 

discussion.  It  seems  to  be  established 
that  the  saliva  possesses  a  very  slight  amylolytic  power,  on  account  of 
the  small  amount  of  ptyalin  at  this  early  age. 

At  birth  the  gastric  glands  secrete  pepsin  in  very  small  quantity. 
Free  hydrochloric  acid  is  not  found.  Lactic,  which  is  mentioned  as  the 
principal  acid  of  the  infant  stomach,  is  found  only  after  the  ingestion 
of  milk.  The  mucous  follicles  secrete  freely.  The  stomach  at  this  early 
age  is  more  of  a  receptacle  for  food  than  a  digestive  organ,  coagulation 
of  albumin  by  the  rennet  ferment  representing  nearly  the  whole  extent 
of  digestion  accomplished  in  this  viscus.  It  is  claimed,  however,  that  a 
considerable  amount  of  fat  is  absorbed  from  its  surface,  through  the 
agency  of  the  lymphoid  corpuscles,  in  which  the  stomach  is  particularly 
rich  at  this  period. 

The  duodenum  contains,  besides  the  intestinal  juices,  the  secretions 
from  the  liver  and  pancreas.  The  importance  of  the  liver  as  a  digestive 
organ  has  long  been  recognized,  but  much  difference  of  opinion  in  regard 
to  the  exact  role  played  by  its  secretion  still  exists. 

"  The  bile  of  the  new-born  is  distinguished  by  its  poverty  in  the 
inorganic  salts  (with  the  exception,  however,  of  iron  salts),  its  poverty 
in  cholesterin,  lecithin,  and  fat,  and  particularly  by  the  small  percentage 
of  special  bile  acids."     (Jacubowisch.)     If  the  above  be  true  it  would 


ALIMENTARY    (J ANAL  67 

seem  fortunate  that  the  young  infant  is  well  supplied  with  lymphoid 
tissue,  whose  corpuscles  are  supposed  to  aid  in  the  absorption  of  fat. 

The  paucity  of  bile  acids,  it  is  said,  allows  a  more  complete  action  of 
the  pepsin  and  pancreatic  secretion,  which  is  usually  retarded  in  the 
presence  of  these  acids.  Although  it  is  believed  to-day  that  the  bile  has 
little  if  any  bactericidal  power,  other  secretions  of  the  intestines,  as  well 
as  those  of  the  stomach  and  salivary  glands,  are  known  to  possess  this 
property. 

Of  the  pancreatic  secretion  it  has  been  shown  that  three  of  its  fer- 
ments are  present  at  birth, — viz.,  trypsin,  steapsin,  and  a  milk-curdling 
ferment.  But  little  amylolytic  action  has  been  demonstrated,  although 
its  proteolytic  and  lipolytic  ferments  are  unquestionably  active.  It  is 
thus  seen  that  digestion  is  carried  on  to  the  greater  extent  in  the  duo- 
denum and  small  intestine. 

No  bacteria  are  found  in  the  intestines  or  their  contents  at  birth. 
Within  twenty-four  hours,  however,  two  varieties  are  found  in  great 
abundance, — viz.,  bacterium  lactis  asrogenes  in  the  small  intestines  and 
bacterium  coli  commune  in  the  large  intestines  and  fasces.  Shortly  after 
birth,  and  sometimes  before,  meconium  is  discharged.  This  continues 
until  the  fasces  are  changed  by  the  ingestion  of  milk,  which  produces 
light  yellow,  slightly  sour  and  batter-stools  of  uniform  consistency. 
Decomposition  products — as  indol,  skatol,  and  phenol,  with  color 
changing  to  green — are  normally  found  in  stools  that  are  kept  long 
after  discharge.  The  number  of  stools  may  vary  within  physiological 
limits  from  one  to  six  daily. 

Meconium  is  a  viscid,  tarry-colored,  odorless  substance,  feebly  acid, 
containing  no  bacteria.  It  is  composed  of  intestinal  mucus,  bile,  vernix 
caseosa,  epithelial  cells  from  the  epidermis,  hair,  fat-globules,  cholesterin 
crystals ;   also  fatty  acids  and  soaps. 

URINE. 

The  size  and  complete  development  of  the  kidneys  at  birth  would 
suggest  a  somewhat  prolonged  previous  function.  The  finding  of  the 
constituents  of  the  urine  in  liquor  amnii  is  evidence  of  their  eliminative 
activity.  Urine  is  normally  present  in  the  bladder  at  birth  and  is 
usually  voided  within  a  short  time,  any  delay  beyond  twelve  hours 
occasioning  some  anxiety.  The  first  urine  voided  is  clear  and  of  a  pale 
amber  color,  unless  long  retained,  in  which  case  it  is  dark  and  cloudy. 
Its  specific  gravity  varies  from  1.012  to  1.005,  and  the  reaction  is  acid. 

A  frequent  marked  peculiarity  in  the  new-born  is  the  presence  of 
uric  acid  crystals,  so  abundant  sometimes  as  to  form  infarcts  in  the 
straight  tubules  of  the  kidney,  even  to  the  extent  of  their  complete 
occlusion. 

Traces  of  albumin  and  hyaline  casts  occasionally  appear.  Urea  and 
inorganic  salts  are  not  found  in  large  amounts  during  the  first  week, 
hence  the  low  specific  gravity.  The  quantity  of  urine  in  the  first  day 
varies  from  nothing  to  two  ounces   (60  C.c).     "With  the  ingestion  of 


68     PHYSIOLOGY   AND    HYGIENE    OF    THE    NEW-BORN 

fluids  there  is  a  corresponding  increase  in  the  amount  voided;  so  that 
by  the  end  of  the  first  week  it  may  range  from  five  to  thirteen  ounces 
(150-390  C.c).  Because  of  the  small  size  of  the  bladder  and  the  lack 
of  inhibitory  control  of  the  sphincter,  micturition  is  frequent  at  this  age, 
often  thirteen  to  fifteen  times  in  twenty-four  hours.  A  tenacious  vaginal 
discharge,  which  may  be  bloody,  is  occasionally  seen  in  the  first  few  days. 

SKIN. 

The  part  played  by  the  integument  in  the  animal  economy  is  such  as 
to  necessitate  great  activity  in  its  growth  and  repair.  Hence  it  is  not 
surprising  to  find  that  it  has  the  most  abundant  blood  supply,  with  the 
greatest  glandular  activity.  The  skin  of  the  infant  is  thin,  delicate, 
velvety  to  the  touch,  and  elastic  to  accommodate  the  varied  movements. 
Its  thinness  and  numerous  capillaries  give  to  it  the  characteristic  pink- 
ness  of  infancy.  It  is  evidently  well  prepared  histologically  for  frequent 
renewal  and  rapid  growth  necessitated  by  the  constant  attrition  and 
expansion.  The  skin  demands  constant  care  to  prevent  irritation  and 
excoriation,  especially  about  the  buttocks,  from  the  urine  and  fasces.  It 
seems  hardly  necessary  to  remark  that  the  napkin  should  be  removed  as 
soon  as  it  is  soiled. 

Disappearance  of  the  lanugo,  and  exfoliation  of  the  primitive  epi- 
dermis, begin  with  the  exposure  to  the  air,  and  continue  throughout  the 
first  two  or  three  weeks.  During  this  time  the  stump  of  the  umbilical 
cord  separates  from  the  surface  of  the  abdomen,  by  a  line  of  demarca- 
tion, leaving  a  cicatrix,  occasionally  denuded  of  epithelium. 

SEBACEOUS   GLANDS. 

The  function  of  the  sebaceous  glands,  active  from  the  middle  of  intra- 
uterine life,  continues  after  birth,  hence  unremitting  care  is  required 
to  prevent  accumulations,  especially  on  the  scalp.  If  crusts  are  once 
formed,  frequent  oiling  may  be  necessary  to  soften  them.  Too  frequent 
use  of  strong  soap  and  water,  as  well  as  friction,  should  be  avoided. 

SWEAT   GLANDS. 

The  sudoriferous  glands  are  inactive  at  birth,  and  perspiration  is 
not  usually  seen  during  the  first  weeks. 

LACHRYMAL    GLANDS. 

The  function  of  the  lachrymal  glands  is  not,  as  a  rule,  established  at 
birth,  tears  usually  making  their  appearance  about  the  third  month. 

NERVOUS   SYSTEM. 

In  regard  to  the  functions  of  the  nervous  system,  it  may  be  said  that 
at  birth  the  infant  is  merely  a  bundle  of  reflexes,  although  its  reflex 
excitability  lacks  the  intensity  shown  later.  Inhibition  is  poorly  devel- 
oped and  the  motor  centres  are  quickly  exhausted.  A  certain  degree  of 
myotonia  and  athetosis  is  normal  in  the  young  infant  (Figs.  4  and  5). 


CARE    OF    TIIK    NEW-BORN  69 


SIGHT. 

It  appears  that,  although  the  eye  is  complete  in  formation  at  birth, 
the  infant  has  but  feeble  vision,  it  is  evident  from  the  play  of  features 
that  a  difference  iu  the  intensity  of  light  is  appreciated  before  the  end 
of  the  first  day.  On  the  second  day  the  eye  is  quickly  closed  on  bringing* 
a  candle  flame  near. 

HEARING. 

The  sense  of  hearing  is  probably  not  present  at  birth,  but  is  estab- 
lished within  the  first  day  or  two,  as  the  tympanum  fills  with  air  and 
the  congestion  of  its  mucous  membrane  subsides. 

SMELL. 

In  all  probability  smell  is  the  last  of  the  special  senses  to  develop. 

TASTE. 

The  sense  of  taste  is  evidently  well  developed  from  birth,  the  young 
infant  readily  distinguishing  milk  from  water. 

TOUCH. 

Tactile  sensation  is  very  acute  in  the  lips,  tongue,  and  eyes,  although 
feeble  in  other  areas.  Many  reflexes — as  respiration,  peristalsis,  swallow- 
ing, winking,  coughing,  and  sneezing — exhibit  a  remarkable  prenatal 
development  of  mechanism. 

CARE   OP    THE    NEW-BORN. 

From  the  foregoing  it  is  evident  that  the  new-born  is  entirely  at  the 
mercy  of  his  surroundings.  In  fact,  of  all  the  mammalia,  the  human 
infant  is  the  most  helpless.  The  first  duty  after  delivery  is  to  see  that 
his  respiratory  passages  are  free  from  secretions.  This  is  aided  by  in- 
verting the  child  and  gently  slapping  the  back  of  the  chest  with  the 
hand.  Careful  introduction  of  the  finger  wrapped  with  dry  gauze  may 
be  necessary  to  clear  the  larynx.  The  eyes  should  be  cleansed  from  secre- 
tions by  washing  with  pure  water  or  boric  acid  solution.  The  child 
should  be  received  in  a  warm,  dry  blanket  and  his  entire  surface  anointed 
with  warm  olive  oil  or  lard.  The  cord  may  be  freely  dusted  with  boric 
acid  and  surrounded  with  gauze  or  absorbent  cotton,  or  it  may  be 
cleansed  with  alcohol  and  dressed  without  powder. 

Placing  the  baby  on  the  right  side  presumably  favors  the  closure  of 
the  foramen  ovale,  and  prevents  undue  pressure  from  the  heavy  liver, 
in  which  position  it  may  be  left  undisturbed  for  half  an  hour  or  more, 
after  which  the  thoroughly  emulsified  vernix  caseosa  is  easily  removed  by 
further  inunction  and  gentle  wiping  with  soft  gauze.  The  navel  dress- 
ing should  be  retained  by  a  light  flannel  abdominal  band,  the  simple 
garments  adjusted,  and  the  child  laid  in  a  warm,  dark  place  for  necessary 


70      PHYSIOLOGY   AND    HYGIENE    OF    THE    NEW-BORN 

repose.  It  is  well  to  administer  at  this  time  a  teaspoonful  or  two  of 
warm  sterilized  water. 

Too  much  stress  cannot  be  laid  upon  the  avoidance  of  all  that  tends 
to  shock  or  fatigue,  and  the  observance  of  absolutely  aseptic  details. 

It  is  advisable  to  place  the  infant  at  the  breast  within  a  few  hours 
after  birth  (the  nipples  having  previously  been  cleansed  with  boric  acid 
solution)  as  it  is  believed  that  the  colostrum  at  this  time  is  adapted  to 
the  needs  of  the  infant 's  digestive  tract. 

It  must  always  be  remembered  that  an  infant's  needs  are  few  but 
imperative — warmth,  food,  and  repose.  He  should  be  disturbed  only  for 
his  daily  inunctions,  change  of  clothing,  care  of  eyes  and  nose,  also  for 
fresh  napkins,  or  for  food  or  drink.  He  should  be  put  to  the  breast 
every  two  or  three  hours  during  the  day  and  once  at  night.  The  prac- 
tice of  allowing  the  child  to  sleep  by  the  side  of  the  mother  should  not  be 
encouraged. 


CHAPTER    IV 

PHYSIOLOGY  OF  THE  FIRST  YEAR 

DEVELOPMENT    OF    THE    SPECIAL    SENSES 

A  definite  knowledge  of  what  constitutes  normal  function  is  no  sim- 
ple matter,  since  during  the  period  of  development  not  only  are  organs 
growing,  but  their  separate  and  correlative  functions  are  developing. 
Some  mechanisms  reach  their  complete  perfection  as  to  histologic  struc- 
ture while  others  are  still  in  the  formative  stage.  Observations  on  the 
motor  oculi  nerve  show  the  perfection  not  only  of  its  mechanism,  but  also 
of  its  function  at  an  early  period  of  infancy.  This  illustrates  the  method 
of  growth,  since  this  mechanism  furnishes  one  of  the  channels  of  infor- 
mation before  the  higher  centres  are  capable  of  utilizing  it,  the  process 
being  an  educational  one.  Thus  it  is  seen  that  all  the  special  senses 
contribute  to  the  development  of  the  higher  centres  from  which  comes 
the  evolution  of  ideas,  these  (special  senses)  in  turn  having  been  preceded 
by  the  lowest  form  of  nervous  phenomena, — viz.,  reflex  action. 

The  nervous  system  of  the  infant  shows  well  developed  sensory  and 
motor  tracts,  but  the  inhibitory  power  of  the  higher  centres  is  tardier 
in  its  growth. 

It  is  seen  that  taste  and  tactile  sensibility,  especially  of  the  lips  and 
tongue,  are  the  first  of  the  special  senses  to  show  activity ;  fortunately, 
as  these  are  necessary  in  the  instinctive  efforts  of  the  young  to  obtain 
sustenance. 

Hearing,  although  demonstrated  as  present  in  the  first  twenty-four 
hours,  is  not  developed  sufficiently  to  differentiate  between  the  mother's 
tones  or  the  sounds  accompanying  the  preparation  of  food,  and  other 
noises  irrelevant  to  the  infant's  daily  requirements,  before  the  third 
month. 

Although  sensitiveness  to  light  and  blinking  on  the  near  approach 
of  objects  has  been  observed  from  the  first  weeks,  still  it  is  not  until  the 
end  of  the  second  month  that  the  infant  recognizes  his  mother  by  sight. 

From  birth  the  grasp  of  the  hand  upon  any  object  touching  the  palm 
is  remarkably  tenacious  and  the  normal  position  of  the  fingers  is  that  of 
extreme  flexion.  The  voluntary  muscles  show  movements  which  are 
purposeless,  irregular  and  asymmetrical,  and  suggestive  of  the  mere 
continuance  of  intrauterine  existence.  Co-ordinate  voluntary  move- 
ments are  first  seen  in  the  face  and  upper  extremities,  the  hands  showing 
prehensile  propensities  by  the  end  of  the  third  month.  Objects  are  car- 
ried to  the  mouth  at  about  this  time.  The  many  ineffectual  attempts  to 
locate  the  mouth  indicate  the  vast  amount  of  energy  necessary  to  develop 
co-ordination.     Although  the  apparatus  including  muscles  and  nerves, 

71 


72  PHYSIOLOGY    OF    THE    FIRST    YEAE 

both  afferent  and  efferent,  is  fairly  complete,  it  is  seen  that  multiple 
repetitions  of  sensations,  impressions,  volitions,  and  efforts  must  occur 
ere  the  establishment  of  perfect  co-ordination  for  the  performance  of  the 
simplest  voluntary  motion. 

It  is  not  until  about  the  end  of  the  third  month  that  the  cry  is  recog- 
nized as  expressing  emotions,  such  as  anger,  hunger,  pain,  and  the  sounds 
indicative  of  pleasure.  The  transition  from  cry  to  voice  depends  upon 
the  operation  of  larynx,  mouth,  and  tongue.  About  this  time  tears  are 
observed  to  accompany  the  crying.  It  is  interesting  to  note  that  per- 
spiration is  not  common  before  the  end  of  the  third  month.  Exception- 
ally, the  appearance  of  these  two  secretions  has  been  observed  at  a  much 
earlier  period.  The  salivary  glands,  also,  seem  to  develop  activity,  drool- 
ing being  a  marked  feature  after  the  third  month.  It  is  claimed  that  the 
saliva  at  this  time  possesses  the  power  of  starch  conversion  to  a  limited 
degree. 

Following  the  development  of  the  senses  of  sight  and  hearing  to 
the  extent  of  differentiating  as  to  the  color  and  size  of  objects  and  the 
quality  and  direction  of  sound,  we  find  co-operation  of  the  muscles  of 
the  neck  to  a  degree  that  the  infant's  head  is  held  erect,  balanced,  and 
turned  at  will. 

Although  at  birth  well  supplied  with  sensory  apparatus  and  well 
developed  tactile  corpuscles,  sensitiveness,  with  the  exception  of  mouth 
and  lips,  is  dull  in  the  young  infant,  or  rather,  slow  to  respond  to  irri- 
tation ;  the  association  paths  of  nerve  force  not  yet  having  become  estab- 
lished by  frequent  repetition  of  impressions.  After  the  third  month 
sensation  is  generally  well  developed  over  the  entire  body ;  the  forehead 
and  external  auditory  meatus,  it  is  said,  being  particularly  sensitive. 

From  the  sixth  to  the  tenth  month  the  infant  should  sit  without  sup- 
port and  soon  develop  automobility,  as  seen  in  creeping,  rolling,  or  hitch- 
ing toward'  desired  objects.  About  this  time  he  usually  utters  a  few 
indefinite  syllables,  singly  or  repeated,  as  pa,  ma,  go,  goo,  etc. 

By  the  twelfth  month  he  is  usually  able  to  stand  by  a  chair  and,  ex- 
ceptionally, may  walk  at  the  end  of  the  first  year. 

Infants  exhibit  a  marked  variation  as  to  the  time  of  the  development 
of  these  different  acquirements,  dependent  largely  upon  muscular  vigor, 
education,  and  family  tendency.  A  child  left  much  alone  will  learn  to 
develop  earlier  his  resources. 

During  the  first  six  months  of  life  the  respiration  continues  super- 
ficial and  irregular,  auscultation  giving  a  soft,  indistinct  murmur,  be- 
cause, for  want  of  inspiratory  vigor,  the  air  does  not  fully  expand  the 
alveoli.  The  rate  has  been  variously  stated  from  twenty-five  to  thirty- 
five,  or  even  higher,  in  the  earlier  months. 

The  pulse  rate  averages  from  120  to  140,  is  somewhat  slower  during 
sleep,  and  shows  no  dicrotic  wave. 

During  the  earlier  months  the  temperature  exhibits  a  tendency  to 
fall  below  the  adult  normal.  Pyrexia  is  frequently  the  result  of  trivial 
causes. 


URINE    AND    FAECES  73 

The  urine  increases  from  about  six  ounces  (ISO  C.c.)  at  the  end  of 
the  first  week  to  eight  or  sixteen  ounces  (240  or  480  C.c.)  at  six  months. 
Great  variation  in  this  is  noticeable,  dependent  upon  the  secretions  from 

the  skin  ami  bowels  and  the  amount  of  fluids  imbibed.  The  marked 
tendency  to  micturition  is  variable  from  causes  not  well  understood, 
occurring  sometimes  every  hour  during  the  day  and  twice  or  thrice  at 
night,  while  at  other  times  several  hours  may  elapse  without  urination. 
The  urine  is  usually  light  in  color,  of  low  specific  gravity,  1.004  to  1.010, 
rarely  staining  the  diaper  in  health.  The  inorganic  salts  (phosphates, 
chlorides,  and  sulphates)  increase  in  quantity  as  age  advances  and  urea 
is  more  abundant. 

Sugar  sometimes  appears  in  the  urine  of  infants  in  the  early  months, 
the  result,  it  is  believed,  of  an  excessive  amount  of  saccharine  material 
in  the  food. 

The  fecal  discharges  after  the  first  few  days  are  an  orange  yellow, 
frequently  turning  to  green  on  exposure  to  air,  are  of  the  consistency 
of  batter,  homogeneous  throughout,  inoffensive,  but  of  somewhat  sour 
odor  and  slightly  acid  reaction.  The  fasces  contain  about  eighty-five  per 
cent,  of  wTater  and  average  from  three  to  five  movements  daily.  These 
characteristics  vary  somewhat  with  the  quality  of  food  taken  and  the 
completeness  of  the  digestive  process. 

The  stomach  of  the  infant  at  birth  has  been  found  to  be  little  more 
than  a  receptacle  for  food  in  which  the  action  of  rennet,  coagulating  the 
milk,  prepares  it  for  the  first  step  in  the  digestive  process. 

As  the  infant  grows  the  capacity  of  the  stomach  increases  rapidly,  its 
walls  thicken,  the  gastric  glands  develop  at  the  expense  of  the  mucous 
follicles  and  lymphoid  tissue,  so  that  fat  absorption  is  relatively  less  free, 
while  pepsin  and  hydrochloric  acid  secretions  gradually  become  more 
abundant.  These  changes,  it  is  evident,  increase  the  importance  of  the 
stomach  as  a  digestive  organ. 

During  the  latter  half  of  the  first  year  the  stomach  empties  itself  of 
a  meal  in  from  one  to  three  hours ;  the  time  depending  upon  the  quality 
of  the  food  taken,  cow's  milk  requiring  the  longer  time. 

The  various  complicated  changes  in  the  food  during  digestion  have 
been  described  by  physiologists  under  different  names,  both  as  to  proc- 
esses and  products,  resulting  in  much  confusion  of  ideas.  According 
to  Kirke,  the  food  is  first  changed  into  parapeptone  or  acid  albumin ;  the 
next  step  results  in  propeptones  or  albuminoses ;  the  third  or  final  step 
is  represented  by  the  diffusible  peptones,  the  finished  product  of  gastric 
digestion.  The  last  process,  however,  applies  only  to  a  limited  portion  of 
the  stomach  contents,  for  in  the  infant  a  part  of  the  food  soon  escapes 
because  of  unguarded  pylorus ;  early  relaxation  occurring  from  the  easily 
exhausted  muscular  structure.  A  portion  of  the  water,  milk-sugar.  f;its, 
and  salts  are  absorbed  from  the  surface  of  the  stomach  directly  into  the 
blood. 

The  bile,  by  neutralizing  the  acidity  of  the  chyme  as  it  emerges  from 
the  pylorus,  favors  the  process  of  pancreatic  digestion,  which  is  active 


74  PHYSIOLOGY    OF    THE    FIRST   YEAE 

only  in  alkaline  media.  As  previously  observed,  the  pancreatic  secretion 
in  the  new-born  shows  proteolytic  action  (the  power  of  digesting  albu- 
minoids), lipolytic  action  (the  power  of  reducing  fats),  and  the  presence 
of  a  milk-curdling  ferment;  but  the  amylopsin  (the  starch-digesting 
ferment)  is  slight.  It  is  claimed  that  although  a  trace  of  this  ferment 
has  been  found  at  birth,  it  is  not  present  in  sufficient  quantity  to  exert 
much  influence  on  starch  until  toward  the  middle  of  the  first  year. 

Radical  differences  of  opinion  obtain  in  regard  to  the  relative  amount 
of  starch  conversion  by  the  enzymes  of  the  saliva,  pancreatic  secretion, 
bile,  and  succus  entericus ;  also  as  to  the  age  at  which  they  first  become 
practically  active.  Recent  observations  assign  greater  importance  to  the 
amylolitic  processes  in  young  infants  than  was  formerly  accorded. 

The  importance  of  the  different  times  of  development  of  these  active 
agents  in  the  pancreatic  secretion  is  evident  in  its  relation  to  the  dif- 
ferent constituents  of  food  acted  upon,  because  it  suggests  the  varying 
quality  of  aliment  demanded  by  the  child  at  the  different  stages  of  his 
growth. 

A  striking  analogy  is  seen  between  the  gastric  and  duodenal  digestive 
processes;  the  pancreatic  juices  exercising  in  alkaline  media  functions 
quite  similar  to  those  of  the  gastric  juices  in  acid  media.  It  is  a  common 
error  to  assume  that  the  stomach  is  responsible  for  a  certain  completed 
change  in  the  aliment,  converting  it  into  a  substance  called  chyme,  wholly 
unlike  that  ingested,  and  that  secondarily  the  duodenum  further  changes 
this  chyme  into  a  totally  different  substance,  known  as  chyle,  in  which 
form  only,  absorption  is  possible.  The  facts  seem  to  be  that  digestion 
in  its  entirety  does  not  begin  with  the  stomach  and  end  with  the  ileum, 
but  that  this  process,  accompanied  by  absorption  of  some  portion  of  the 
food,  may  occur  in  the  mouth,  in  the  stomach,  in  the  duodenum,  and 
throughout  the  alimentary  tract.  The  saliva,  which  is  known  to  act  not 
only  in  the  mouth,  but  in  the  stomach  as  well,  proceeds  with  its  conversion 
of  starch  until  rendered  inert  by  the  excess  of  hydrochloric  acid — a  period 
of  from  fifteen  minutes  to  two  hours.  The  amylopsin  from  the  pancreas 
acts  similarly  on  the  starches  later  on  in  the  duodenum.  The  milk- 
curdling  ferment  of  the  stomach  coagulates  albumin  in  the  acid  medium, 
while  that  of  the  pancreas  is  acting  similarly  in  an  alkaline  media.  The 
pepsin  of  the  stomach,  after  the  action  of  the  HC1,  converts  acid-albumin 
into  peptones.  The  trypsin  of  the  pancreas,  after  the  action  of  the  bile, 
converts  alkali-albumin  into  peptones,  absorption  taking  place  wherever 
and  whenever  the  histological  structures  of  the  digestive  tube  and  the 
character  of  the  adjacent  aliment  favor  that  process. 

A  better  understanding  of  the  digestive  processes  of  infancy  has  al- 
ready resulted  from  facts  recently  established  by  van  Slyke  and  Hart 
in  their  studies  on  the  production  of  cheddar  and  cottage  cheeses,  in 
regard  to  the  chemical  behavior  of  caseins  in  the  presence  of  acids,  rennet, 
and  pepsin.  Dr.  Thomas  S.  Southworth,  in  an  article  on  this  subject 
(Medical  Record,  March  4,  1905),  says: 

"  These  discoveries  make  it  clear  that  acids  have  a  definite  chemical 


DIGESTION    OF    .MILK  75 

action  upon  calcium  casein  and  calcium  paracasein,  and  have  furm 
proof  that  no  gastric  digestion  by  pepsin  takes  place  until  calcium  casein 
or  calcium  paracasein  has  been  acted  upon  by  acid  and  converted  either 
into  free  casein  or  free  paracasein    (base-free  proteids),  or  into  their 

compounds  with  acid. 

"  Casein  as  it  exists  in  milk  is  called  calcium  casein.  The  rennet  clot 
of  milk  is  called  calcium  paracasein.  The  products  resulting  from  1 1n- 
action of  small  amounts  of  acid  upon  these  two  bodies,  formerly  called 
mono-acid  salts,  are  now  known  as  free  casein  and  free  paracasein.  Those 
resulting  from  the  action  of  larger  amounts  of  acids,  formerly  called 
di-acid  salts,  are  now  known  as  lactate,  hydrochloride,  etc.,  of  casein  and 
paracasein. 

"  The  first  secretion  of  the  stomach  of  the  young  is  the  ferment, 
rennin.  The  rennet  ferment  acts  upon  the  calcium  casein  of  the  milk, 
forming  a  soft  clot,  which  is  called  calcium  paracasein  (junket)..  If 
no  acid  is  present,  this  paracasein  clot  may  pass  on  into  the  intestine, 
where  it  is  readily  digested  by  the  pancreatic  and  intestinal  secretions. 
The  pepsin  secreted  by  the  stomach  will  not  attack  calcium  paracasein 
in  the  absence  of  acid.  But  when  hydrochloric  acid  begins  to  be  secreted 
by  the  stomach  this  reacts  with  the  calcium  paracasein  formed  by  the 
action  of  the  rennet  ferment,  making  first  free  paracasein  and  then  a 
definite  chemical  compound  known  as  hydrochloride  of  paracasein,  which 
is  fitted  for  gastric  digestion  and  is  now  readily  attacked  by  pepsin,  and 
true  stomach  digestion  begins. 

"  The  physical  character  of  these  curds,  both  in  size  and  density, 
varies  according  to  the  species  of  the  mammal,  and  the  free  paracasein 
and  hydrochloride  of  paracasein  curds  have  a  tendency  to  shrink  and 
become  more  or  less  tough,  depending  upon  the  kind  of  milk.  This  ten- 
dency to  shrink  into  tough  curds  is  especially  marked  in  cow's  milk. 

"  The  digestion  of  the  infant  is  in  process  of  evolution  and  is  not 
to  be  thought  of  as  the  same  as  the  digestion  of  the  adult.  In  the  adult, 
gastric  digestion  is  accomplished  by  the  hydrochloric  acid  and  pepsin 
of  the  gastric  juice,  which  also  disintegrates  the  food  which  leaves  the 
mouth  in  particles  of  varying  size.  Digestion  progresses  most  rapidly 
when  free  acid  is  present.  In  the  young  animal  whose  gastric  function 
is  in  process  of  development,  and  who  secretes  at  first  no  acid  and  later 
but  gradually  increasing  amounts,  coarse  food  causes  disturbances  for 
some  time  after  birth,  until  both  the  stomach  and  its  secretions  are  devel- 
oped. It  is  one  of  the  most  remarkable  things  in  nature  that  milk,  which 
itself  retains  practically  the  same  composition  throughout  lactation,  is 
changed  by  the  action  upon  it  of  the  developing  gastric  secretions  into 
forms  and  compounds  which  require  at  first  moderate,  and  later  more 
extended,  gastric  digestion,  by  which  means  the  stomach  is  progressively 
called  upon  to  perform  more  and  more  work,  until  it  is  sufficiently  de- 
veloped to  begin  its  subsistence  upon  the  types  of  food  consumed  by  the 
adult  of  its  species. 

"  If  the  stomach  secretes  a  small  amount  of  acid  only,  but  little  of 


76  PHYSIOLOGY    OF    THE    FIRST    YEAR 

the  soft  calcium  paracasein  clot  is  changed  into  the  somewhat  tougher 
free  paracasein  through  the  union  of  the  acid  with  the  calcium.  The 
free  paracasein  is  readily  dissolved  in  dilute  salt  solution,  which  suggests 
an  explanation  of  the  good  results  claimed  from  the  addition  of  salt 
to  the  infant's  bottle.  With  such  moderate  secretion  of  acid  by  the 
stomach,  a  part  only  of  the  calcium  paracasein  is  therefore  prepared  for 
gastric  digestion  by  pepsin,  while  the  remainder  of  the  soft  unaltered 
calcium  paracasein,  which  cannot  be  attacked  by  pepsin,  passes  on  into 
the  intestine,  where  it  undergoes  digestion  by  the  intestinal  ferment, 
trypsin,  and  other  digestive  secretions.  A  still  more  abundant  secretion 
of  gastric  juice — i.e.,  of  hydrochloric  acid  plus  pepsin — will  change  more 
of  the  milk  into  a  form  suited  for  gastric  digestion  than  a  less  abundant 
secretion.  Thus  the  work  performed  by  the  stomach  is  normally  regu- 
lated automatically. 

"  But  this  is  not  all,  for  when  hydrochloric  acid  comes  to  be  present 
in  amounts  greater  than  is  necessary  to  form  free  paracasein  with  those 
parts  of  the  calcium  paracasein  clot  which  it  can  readily  attack,  depend- 
ing upon  the  size  and  density  of  the  curds,  the  excess  of  acid  unites  with 
some  exposed  portions  of  the  free  paracasein  in  such  a  way  as  to  form 
a  definite  compound,  hydrochloride  of  paracasein.  Such  a  salt  of  para- 
casein is  more  difficult  to  digest  in  the  absence  of  uncombined  a,cid  in  the 
stomach  than  free  paracasein,  but  when  there  is  acid  enough  secreted 
by  the  stomach  to  also  give  uncombined  free  acid,  the  acid  compounds 
of  paracasein  are  more  readily  digested  by  pepsin.  These  changes  in 
the  curds  increase  the  scope  and  task  of  gastric  digestion  by  which  the 
developing  stomach  is  trained  to  cope  with  more  and  more  difficult  prob- 
lems in  its  preparation  for  its  future  task  of  digesting  the  solid  food  of 
adult  life.  But  since  the  calcium  paracasein  clot  is  attacked  upon  its 
surface  by  acid,  and  since  the  curds,  especially  of  the  milks  of  different 
species,  may  vary  much  in  size  and  density,  the  chemical  action  of  the 
acid  may  penetrate  them  to  different  degrees,  and  it  is  consequently 
entirely  possible  to  have  at  the  same  time  within  the  curd  or  in  the 
gastric  contents,  in  varying  proportion,  paracasein  hydrochloride,  free 
paracasein,  and  calcium  paracasein,  depending  either  upon  the  admixture 
or  contact  of  the  acid  with  the  stomach  contents  or  upon  the  strength 
and  quantity  of  the  gastric  secretions." 

That  a  very  large  percentage  of  the  aliment  is  absorbed  in  the  nor- 
mal infant  normally  fed  is  shown  by  analysis  of  the  faeces.  Their  physi- 
cal characteristics  have  been  already  described.  As  a  result  of  his  obser- 
vations upon  infants  fed  wholly  upon  milk,  Escherich  states  that  the 
faeces  consist  of  eighty-four  to  eighty-six  per  cent,  water ;  that  digestion 
and  absorption  of  proteids  in  the  alimentary  canal  are  so  efficient  that 
but  little  is  lost;  that  the  whitish  flakes  and  clots,  nearly  always  seen, 
are  composed  largely  of  fat,  and  fatty  and  lactic  acids  in  combination 
with  lime ;  while  cholesterin,  traces  of  bilirubin,  intestinal  epithelium, 
and  mucus  may  also  be  detected.  In  addition,  large  quantities  of  bac- 
teria are  always  present;   a  fine,  slender  bacillus,  named  by  this  author 


IMPORTANCE    OF    THE    STUDY    OF    PHYSIOLOGY        77 

the  bacterium  lactis  aerogenes,  and  the  polymorphic  bacterium  coli  com- 
mune being  llie  two  chief  kinds.  Milk  acids  are  always  found,  and  to 
their  presence  should  be  attributed  the  acid  reaction.  Fermentation  of 
milk-sugar  Leads  to  the  development  of  carbon-dioxide  and  hydrogen, 

which  are  the  principal  gases  in  the  intestinal  tract  of  a  healthy   in- 
fant fed  purely  on  milk,  foul-smelling  gases  being  conspicuous  by  their 
absence.     Though  the  amount  of  faeces  varies  much  in  sucklings 
three  per  cent,  of  the  milk  ingested  is  the  average  proportion. 

It  is  by  the  study  of  the  digestive  processes  at  different  periods  that 
the  problem  of  physiological  feeding  must  be  solved.  To  him  who  would 
not  only  secure  the  highest  results  in  infant  nutrition,  but  also  deter- 
mine some  of  the  questions  as  to  the  etiology  of  digestive  disturbances 
with  their  intricate  pathological  sequelae,  the  study  of  the  physio-chemics 
of  digestion  will  be  fraught  with  interest.  It  is  true  that  much  remains 
to  be  learned  concerning  digestion,  assimilation,  and  nutrition,  but  con- 
fessed ignorance  in  regard  to  certain  ultimate  processes  affords  no  excuse 
for  gross  disregard  of  the  knowledge  already  obtained.  The  child  must 
be  fed  with  due  reference  to  the  physiological  demands  of  the  period  or 
stage  of  development  of  the  growing  organism. 

Considerable  space  has  been  given  to  the  study  of  infantile  anatomy 
and  to  the  consideration  of  physiology,  sufficient,  it  is  hoped,  to  at  least 
lay  the  foundation  for  the  study  of  the  phenomena  to  be  observed  in 
early  infancy.  That  the  purpose  of  this  method  of  study  may  be  more 
apparent,  the  subject  of  hygiene  of  the  infant  at  this  period  will  now 
be  taken  up.  In  fact,  the  ultimate  purpose  of  this  study  should  find  its 
consummation  in  the  establishment  of  some  general  principles  or  rules 
of  management,  by  the  application  of  which  may  be  secured  to  the  infant 
the  best  conditions  required  by  the  peculiarities  of  his  organization. 

Man,  as  a  finished  entity,  furnishes  a  study  of  great  complexity  as 
to  his  physiologic  and  hygienic  requirements.  How  much  more  intricate, 
then,  must  be  the  problem  as  to  the  requirements  of  the  independent  and 
correlated  processes,  during  the  ever-changing  phases  of  the  transitional 
periods  of  infancy. 

Among  all  the  obstacles  to  be  overcome,  two  things  particularly  stand 
in  the  way  of  the  application  of  the  principles  of  hygiene  of  infancy: 
First,  there  is  a  want  of  information  on  the  part  of  the  physician,  or  a 
disinclination  to  apply  his  knowledge ;  second,  the  unwillingness  of  the 
mother  to  be  guided  in  this  respect.  Two  erroneous  conclusions  have 
taken  firm  hold  of  the  lay  mind,  and  to  some  extent  of  the  professional 
mind  also.  One  is,  that  the  maternal  instinct  endows  the  mother  with  a 
knowledge  that  is  sufficient  for  all  the  requirements  of  the  infant ;  the 
other  is,  that  the  representative  of  science,  however  highly  endowed, 
knows  but  little  of  the  requirements  of  the  babe  because  of  the  inability 
to  furnish  verbal  information. 


CHAPTER   V 

HYGIENE    OF    THE    FIRST    YEAR 

PROTECTION    AND    FOOD 

PEOTECTION 

The  absolute  wants  of  the  infant  are  few  and  simple  and  may  be 
expressed  in  the  two  words,  protection  and  food.  The  relative  wants 
which  are  the  outgrowth  of  efforts  to  supply  these  are  numerous  and 
complicated. 

The  infant  must  be  protected  from  shock,  to  which  he  is  peculiarly 
susceptible.  Normal  function,  as,  for  example,  digestion,  may  be  arrested 
or  perverted  through  shock  alone.  It  may  occur  from  sudden  changes 
of  temperature,  from  noise,  from  blows  or  jars,  from  unaccustomed 
motion,  from  fear  or  anger,  from  intense  light,  and  from  excessive  or 
prolonged  pain. 

He  should  be  protected  from  fatigue  of  the  muscles,  due  either  to 
excessive  use  or  prolonged  restraint,  from  protracted  crying,  and  from 
efforts  to  overcome  obstructed  respiration. 

Protection  should  be  secured  from  infectious  or  irritating  substances 
which  may  be  introduced  into  the  cavities  of  the  body;  from  such  irri- 
tations of  the  surface  or  mucous  membranes  as  are  caused  by  accumu- 
lations from  bladder,  bowels,  and  sebaceous  follicles,  or  from  extraneous 
matter — as  strong  soaps,  corrosive  substances,  and  rough  clothing;  also 
from  rough  handling  in  bathing,  and  finally  from  traumatisms  with  or 
without  infection, — as  falls  and  blows,  especially  on  the  head,  bites  of 
insects,  scratches  or  abrasions  from  pins  or  neglected  nails. 

He  also  needs  protection  from  air  contaminated  by  exhalations  from 
other  people  or  by  gases  from  defective  heating  apparatus,  sewers,  cess- 
pools, garbage,  or  accumulations  of  filth,  from  decomposing  vegetable 
matter  from  swamps  or  from  filthy  streets  and  alleys;  from  flies,  not 
only  because  annoying,  but  as  carriers  of  infection ;  from  household  pets, 
— cats,  dogs,  rabbits,  and  poultry;  from  contact  with  colored  picture- 
books  and  garments;  from  promiscuously  laundered  clothing  and  bed- 
ding, and  from  general  refrigeration,  or  from  lowered  temperature  of  a 
single  part,  as  cold  hands  or  feet. 

The  above  enumeration  suggests  a  few  of  the  many  agencies  through 
which  normal  metabolism  and  growth  may  be  disturbed.  That  ail  these 
items  should  be  carried  in  the  mind  of  the  nurse,  and  the  infant  properly 
protected  in  unspecialized  environment,  is  practically  impossible.  The 
multiplicity  of  needs,  viewed  from  the  above  stand-point,  not  to  mention 
the  item  of  regularity  in  feeding,  bathing,  sleeping,  etc.,  makes  an  im- 
perative demand  for  a  systematic  regime.  This  can  only  be  secured  by 
78 


NURSERY 


79 


means  of  a  separate  nursery  in  which  the  means  to  the  end  are  under  full 
control. 

NURSERY. 

The  room  selected  for  this  purpose  should  be  remote  from  those  in 
daily  use  by  the  family.  It  should  receive  direct  sunlight  during  some 
portion  of  the  day;  should  be  of  sufficient  size  to  secure  ventilation 
without  noticeable  draughts ;  must  be  finished  and  furnished  with  spe- 
cial reference,  in  the  minutest  detail,  to  asepsis, — hence  carpetless,  except 
for  rugs  that  may  be  aired  daily ;  curtainless,  so  far  as  heavy  and  un- 
changeable materials  are  concerned;  devoid  of  mouldings,  pictures,  and 
fixtures  which  invite  lodgement  of  dust.  The  walls  should  be  painted 
to  permit  of  thorough  cleansing  with  water  or  antiseptic  applications. 
There  should  be  double  windows  to  protect  against  draughts  and  to  di- 
minish direct  radiation,  with  a  system  of  heating  and  ventilation  which  is 
under  absolute  control.  Window-screens  and  mosquito- 
netting  are  indispensable  for  summer.  A  thermome- 
ter is  a  necessary  fixture.  It  is  desirable  to  maintain 
an  even  temperature  of  from  75°  to  80°  F.  (24°-26.6° 
C.)  during  the  first  weeks,  after  which  time,  until  the 


Fig.  48— Rubber  bath-tub. 


Fig.  49.— Bath  thermometer. 


child  is  three  months  old,  about  75°  F.  (24°  C.)  is  recommended.  After 
that  it  may  be  gradually  lowered  to  70°  F.  (21°  C).  In  emergencies, 
such  as  the  failure  of  the  heating  apparatus,  or  in  extremely  cold 
weather,  hot-water  bottles  or  flasks  should  be  used  in  the  crib. 

Closets,  cupboards,  or  wardrobes  should  have  no  connection  with  the 
nursery,  nor  should  the  family  bath-room.  In  fact,  the  room  should 
contain  nothing  save  the  furniture  and  articles  indispensable  for  the 
care  of  the  infant.  The  crib  should  be  of  metal,  of  simple  construction, 
and  fitted  with  noiseless  rollers.  The  mattress  should  be  filled  with 
selected  hair,  and  if  a  pillow  be  used  it  should  be  a  very  thin  one  of 
the  same  material.  The  bed  should  be  protected  by  a  rubber  sheet  and 
pad,  and  the  covering  should  be  of  light  wool. 

The  different  articles  necessary  in  a  nursery  are  a  noiseless  clock ;  a 
shaded  light;    a  bath-tub,  flexible  rubber  (Fig.  48)  preferred;    a  bath- 


80 


HYGIENE    OF    THE    FIRST    YEAR 


thermometer  (Fig.  49);  scales  (Fig.  50)  and  measuring-rod;  a  double 
ewer;  soap-dish;  soft  towels  and  wash-cloths  of  gauze,  as  sponges  are 
liable  to  be  neglected;    powder-box,  puff-ball  omitted;    soft  hair-brush 

and  diapers.  A  light,  high,  folding  screen  is 
a  necessary  adjunct.  Door  hinges  should  be 
oiled  and  floors  deadened. 

The  nurse 's  bed  should  occupy  an  ad- 
joining room  with  direct  communication. 

SLEEP. 

A  very  young  infant  should  sleep  twenty 
hours  out  of  the  twenty- four;  in  fact,  all 
the  time  when  not  being  nursed,  bathed,  or 
changed.  No  definite .  statement  can  be  made 
as  to  the  exact  number  of  hours  that  a  babe 
should  sleep  at  a  given  age.  No  error  will 
be  made  if  the  child  be  encouraged  to  sleep 
all  that  he  will  during  the  first  year,  being 
guarded  against  all  noises  and  disturbances. 
Sleep  is  largely  a  matter  of  education.  It 
is  constantly  being  demonstrated  that  in- 
fants can  be  taught  to  sleep,  waking  at  reg- 
ular intervals  for  nourishment.  Rocking  or 
carrying  are  advised  against  as  unnecessary 
and  possibly  harmful.  Putting  foreign 
bodies  in  the  mouth,  as  the  thumb  or  an 
artificial  nipple  for  the  purpose  of  inducing 
sleep  or  quiet,  is  unhygienic  and  irrational. 
The  normal  position  of  the  young  infant 
during  sleep  is  characteristic  and  suggestive 
of  intrauterine  life,  the  limbs  flexed,  the 
hands  under  the  chin,  the  body  turned  to  one  side  or  the  other,  and  the 
spine  assuming  a  continuous  convex  curve.  Any  continued  departure 
from  this  attitude  should  call  for  medical  examination. 

The  sleep  during  the  first  few  days  is  profound,  but  during  the  re- 
mainder of  the  year  it  is  easily  disturbed.    Care  should  be  observed  that 
the  position  of  the  child  is  changed  during  the  longest  sleep  of  the  night. 
A  healthy  child  upon  awaking  or  after  a  bath  usually  indulges  in  a 
vigorous  stretching  of  his  body  and  limbs. 

CLOTHING. 

The  object  of  clothing  for  the  infant  is  to  secure  uniformity  of  tem- 
perature. In  the  ideal  nursery  no  reason  is  apparent  why  one  portion 
of  the  body  requires  heavier  clothing  than  another,  hence  material  of 
uniform  thickness  is  suggested  for  the  protection  of  the  trunk  and  limbs. 
Physiology,  as  well  as  clinical  experience,  furnishes  good  reasons  for 
leaving  the  head  uncovered  in  ordinary  temperatures. 


Fig.  50.— Infant  scales. 


TEMPERATURE  81 

An  almost  universal  error  in  clothing  infants  is  the  neglect  to  allow 
unrestrained  freedom  of  movement  of  all  the  muscular  structures, 
whether  toes,  fingers,  feet,  hands,  legs,  arms,  abdomen,  dorsum,  or 
thorax. 

As  to  the  form  and  texture  of  the  clothing,  that  described  on  pages 
65  and  66  is  suggested,  and  the  advantages  emphasized  of  including  the 
hands  in  the  covering  as  a  prevention  to  the  habit  of  putting  the  fingers 
in  the  mouth.  This  is  a  most  unhygienic  practice:  first,  because  it 
favors  the  introduction  of  infections ;  second,  because  the  subsequent 
chilling  of  the  parts  from  rapid  evaporation  of  moisture  induces  local 
congestions,  causing  symptoms  of  indigestion,  colic,  etc. ;  third,  it  leads 
to  thumb-sucking. 

The  period  during  which  the  hands  should  be  included  in  the  outer 
garment  need  not  exceed  the  first  six  or  eight  weeks  of  life.  It  will  be 
remembered  that  buttons  were  not  provided,  as  much  discomfort  and 
sometimes  positive  injury  results  from  their  pressure  upon  the  delicate 
tissue.  This  is  especially  true,  when,  as  is  frequently  seen,  garments  are 
buttoned  down  the  back. 

The  need  of  protection  against  lowered  temperature  cannot  be  too 
greatly  emphasized.  First,  the  infant  is  peculiarly  susceptible  to  the 
temperature  of  the  surrounding  air,  on  account  of  his  extensive  super- 
ficial area,  as  compared  with  weight.  This,  in  connection  with  the  great 
vascularity  and  thinness  of  the  integument,  gives  a  relatively  enormous 
proportion  of  the  blood  in  close  relation  to  the  surrounding  atmosphere. 
Remembering,  further,  the  fact  that  the  total  quantity  of  blood  is  com- 
paratively small,  it  is  easy  to  see  that  the  circulating  fluids  may  be 
quickly  chilled  in  a  medium  of  lower  temperature.  Second,  normal 
metabolism  requires  a  certain  uniform  temperature,  and  interference  is 
especially  disastrous  during  this  period  of  rapid  growth.  Cold  diverts 
the  process  of  constructive  metamorphosis  into  that  of  heat  production, 
so  that  undue  lowering  of  temperature  interferes  with  growth.  It  also 
results  in  local  disturbances  and  pathological  conditions,  as  congestions, 
catarrh  of  mucous  tracts,  etc. 

The  adult  is  admirably  adapted  to  the  varying  requirements  of  his 
surroundings.  In  no  respect  is  this  better  shown  than  in  his  adaptability 
to  the  extremes  of  temperature,  rendered  possible  through  the  automatic 
operation  of  the  nervous  and  circulatory  mechanisms. 

In  the  infant,  however,  w^  observe  a  want  of  that  harmonious  co- 
operation. "An  unstable  equilibrium"  expresses  the  condition  of  the 
partially  developed  nervous  system  as  well  as  of  the  secretory  and  excre- 
tory apparatuses.  Many  disturbances  from  which  the  adult  organism 
will  recover  easily  its  equilibrium  may  result  in  serious  or  permanent 
injury  to  the  infant.  The  exaggerated  reflexes,  the  imperfected  vaso- 
motor apparatus,  the  undeveloped  muscular  structures,  and  the  transi- 
tional conditions  of  the  glandular  organs,  may  furnish  some  explanation 
for  the  indelible  impressions  resulting  from  marked  vascular  disturb- 
ance or  interrupted  function,  so  often  seen  in  the  young. 

6 


82  HYGIENE    OF    THE    FIRST    YEAR 

That  the  morbid  tendencies  and  processes  which  determine  the  pathol- 
ogy of  later  life  are  thus  established,  there  is  little  reason  to  doubt. 
Figuratively,  the  seeds  of  disease  are  sown  in  infancy,  followed  by  the 
well-known  crops  of  morbid  conditions  familiar  to  the  diagnostician  of 
later  years.  Too  frequently  heredity  suffers  unjust  blame  for  conditions 
which  originated  in  the  neglect  of  hygiene  in  early  infancy. 

BATHS. 

After  the  first  week,  the  strong,  healthy  baby  should  be  bathed  daily, 
and  it  is  not  necessary  to  repeat  reasons  why  this  should  be  done  in  a 
warm  room,  by  the  heater  in  cold  weather,  with  all  currents  of  air  shut 
off  by  the  screen.  The  temperature  of  the  first  baths  should  be  about 
blood  heat — 98.6°  F.  (37°  C).  Gradual  reduction  should  be  practised 
so  that  at  the  end  of  the  month  the  temperature  should  be  95°  F.  (35°  G.)  ; 
at  six  months  90°  F.  (32°  C.),  and  by  the  end  of  the  year  90°  to  85°  F. 
(32°-29°  C.).  It  is  well  to  finish  bathing  and  drying  the  head  before 
undressing  the  baby.  The  convenience  of  the  double  ewer  is  seen  in 
having  a  supply  of  water  free  from  soap  for  rinsing.  Little  soap  is 
required,  and  if  the  skin  be  delicate,  that  known  as  "  superfatty"  is 
advised.  Unless  some  irritation  be  present,  no  powder  should  be  used. 
The  addition  of  bran  to  the  bath  for  children  with  a  tendency  to  eczema, 
and  of  salt,  for  its  stimulating  properties,  to  the  infants  needing  it,  is 
recommended. 

The  daily  bath  should  be  given  midway  between  feedings ;  and  there 
should  be  the  same  regularity  in  this  as  in  all  other  details.  It  should 
not  last  longer  than  five  minutes,  and  the  towelling,  though  thorough, 
must  be  lightly  and  quickly  done. 

Special  care  of  the  eyes,  nostrils,  and  mouth  must  never  be  omitted. 
As  soon  as  the  temporary  teeth  have  erupted,  they  should  receive  as 
faithful  attention  as  the  permanent,  since  they  are  subject  to  caries; 
moreover,  the  effects  in  gastro-enteric  disturbances  are  greater  in  the 
infant. 

In  hot  weather  a  rapid  sponging  with  warm  water  at  night  may 
secure  restful  sleep. 

The  duration  of  the  bath,  as  well  as  the  frequency,  should  depend 
entirely  upon  the  reaction  as  seen  by  its  effects  on  the  capillary  circula- 
tion. A  cyanotic  hue,  chilliness  of  the  surface,  or  signs  of  exhaustion, 
are  always  contraindications  for  frequent  or  prolonged  bathing. 

Preparation  in  every  detail  before  taking  the  child  from  the  crib,  with 
dexterity  in  execution,  will  lessen  many  of  the  evils  of  the  bath. 

The  general  bath  may  occasionally  have  to  be  omitted,  but  nothing 
short  of  a  moribund  condition  should  prevent  local  bathing  and  attention 
to  the  orifices ;  nor  should  the  systematic  changing  of  the  clothing,  prop- 
erly aired  and  warmed,  be  omitted  for  any  less  reason. 

It  is  well  to  bear  in  mind  the  difference  between  tub  and  local 
bathing,  as  the  effects  upon  the  infant  organism  differ  widely. 

It  is  hardly  necessary  to  state  that,  after  bathing,  the  bath  water, 


EXERCISE  83 

towels  and  wet  cloths  should  be  removed  immediately  from  the  room. 
Nor  should  the  nursery  ever  be  used  as  a  drying-room  for  any  fabrics. 
The  filthy  custom  of  hanging  soiled  diapers  to  dry  should  be  condemned. 
In  fact,  they  should  be  immediately  washed.  Diapers  soiled  with  fecal 
discharges,  kept  for  the  inspection  of  the  physician,  should  be  removed 
at  once  from  the  nursery,  as  should  all  others. 

EXERCISE. 

Exercise  is  absolutely  essential  to  the  normal  growth  and  develop- 
ment of  all  the  muscular  structures.  Lusty  crying,  if  not  prolonged  to 
the  point  of  exhaustion,  has  a  beneficial  effect,  in  the  deeper  respiration 
thereby  induced,  with  consequent  improvement  in  oxygenation  and  cir- 
culation. Stretching,  kicking,  squirming,  and  waving  of  arms  secure, 
in  a  measure,  the  needed  exercise.  Once  or  twice  in  the  twenty-four 
hours  the  clothing  may  be  removed  and  the  infant  allowed  the  utmost 
freedom  of  movement.  Occasional  gentle  massage  is  advised,  the  infant's 
expression  of  pleasure  being  one  of  the  immediate  evidences  of  its  bene- 
ficial effects.  After  the  creeping  age  the  infant  usually  secures  enough 
muscular  exercise,  and  must  be  guarded  against  fatigue.  The  creeping 
pen,  raised  a  few  inches  above  the  floor,  is  recommended  for  cleanliness 
and  protection  against  the  floor  draughts  and  contact  with  the  articles  of 
furniture. 

No  matter  how  well  ventilated  the  nursery  may  be,  it  is  essential  that 
the  baby  have  frequent  change  of  air.  Direct  sunlight  is  a  great  desider- 
atum. Differences  of  opinion  exist  as  to  the  age  at  which  infants  should 
be  taken  into  the  open  air.  The  difference  is  probably  due  to  local  pecu- 
liarities of  climate,  and  no  rule  of  procedure  may  be  laid  down  without 
taking  into  consideration  the  climatic  conditions  of  temperature,  humid- 
ity, and  wind.  It  is  advisable  before  taking  the  baby  out  of  doors  that 
he  be  gradually  accustomed  to  the  outside  air  by  opening  the  windows 
of  the  nursery  for  a  short  period  each  day,  keeping  in  mind  the  need  of 
additional  clothing  in  cold  weather. 

With  the  ideal  nursery  the  needs  for  early  outing  are  not  so  impera- 
tive as  where  the  home  surroundings  are  not  conducive  to  the  best 
hygiene.  On  general  principles  the  child  should  have  the  benefit  of  open 
air  and  sunshine  daily  after  the  first  month.  The  more  weakly  the  child 
the  greater  the  need.  One  caution  should  never  be  disregarded :  in  its 
outing,  the  infant  must  be  protected  from  disturbance  in  securing  his 
requisite  amount  of  sleep.  Properly  protected  from  sun  and  wind,  he 
should  spend  the  greater  part  of  the  day  in  the  open  air.  Rocking,  walk- 
ing with,  and  much  coddling  of  infants  should  be  discouraged.  This 
subject  should  not  be  dismissed  without  reference  to  a  practice  that  is 
as  pernicious  as  it  is  common, — viz.,  the  custom  of  regarding  the  baby 
as  a  plaything,  an  animated  toy  for  the  entertainment  of  the  family, 
as  well  as  of  a  large  circle  of  admiring  friends.  Children  are  fond  of 
habies  and  never  tire  of  stimulating  their  funny  performances.  The 
same  is  unfortunately  true  of  parents  and  friends.     From   a  purely 


84  HYGIENE    OF    THE    FIRST    YEAR 

economic  point  of  view  such  amusement  is  exceedingly  expensive,  and 
the  mortality  is  constantly  increased  for  the  amusement  of  the  elders. 
Nervous  and  mental  wrecks  too  frequently  owe  the  origin  of  their 
disorders  to  want  of  repose  in  early  infancy,  due  to  injudicious  stimu- 
lation. In  this  connection  let  it  be  understood  that  all  evidences  of  men- 
tal precocity,  called  ' '  smartness, ' '  should  be  regarded  as  danger  signals, 
and  call  for  repression  rather  than  encouragement.  An  infant  during 
the  first  year  should  neither  be  amusing  nor  amused. 


CHAPTER    VI 
HYGIENE    OF    THE    FIRST    YEAR— Continued 

FOOD 

NATURAL   FEEDING 

For  the  second  essential  requirement  of  the  infant — namely,  nourish- 
ment— ample  provision  has  been  made  by  nature  in  an  apparatus 
admirably  adapted  to  his  requirements. 

Whatever  may  have  been  its  origin,  whether  evolved  through  cycles 
of  physiological  development,  from  the  lacerations  produced  by  the  man- 
dibles of  the  young  marsupials  as  they  clung  to  the  pectoral  integument 
of  the  mother  for  protection,  or  whether  created  in  its  full  perfection  of 
function,  the  mammary  gland  in  its  adjustment  to  the  needs  of  the 
nursing  infant  furnishes  the  highest  example  of  organized  mechanism. 

The  interest  which  centres  about  the  method  of  milk  production  is 
ever  increasing.  The  study  as  to  its  composition  and  the  classification 
of  the  glands  involved — whether  secretory,  excretory,  or  both — is  en- 
gaging the  attention  of  the  best  physiologists.  So,  too,  the  influences 
and  conditions  which  may  affect  its  production  either  by  changing  its 
quantity  or  its  quality  promise  a  fruitful  field  for  the  hygienist.  It  is 
not  without  good  reason  that  attention  is  directed  to  the  subject  of  lac- 
tation, for  in  the  disturbance  or  perversion  of  this  function  is  found, 
perhaps,  the  most  prolific  cause  of  the  disorders  of  infancy.  The  increase 
of  interest  in  this  line  of  study  is  largely  due  to  a  rapidly  growing  ten- 
dency to  ignore  the  normal  method  of  nourishing  the  young.  As  a  result 
of  this  tendency  is  seen  increased  pathologic  conditions  and  a  higher 
rate  of  mortality  in  infancy,  with  subnormal  development  and  diminished 
vigor  of  those  who  survive  the  suckling  period. 

During  gestation  the  evidences  of  provision  for  the  establishment  of 
this  function  are  seen  in  increased  physiological  activity  of  the  mammary 
glands.  The  increase  in  size  and  firmness  of  the  breasts,  the  changes  in 
color  and  texture  of  the  integument,  areolas,  and  nipples,  and  the  en- 
largement of  superficial  veins,  are  all  phenomena  which  so  commonly 
accompany  the  pregnant  state  as  to  be  accepted  signs  of  that  condition. 

Even  during  gestation  a  milky  substance  is  not  infrequently  seen  to 
exude  from  the  orifices  of  the  nipples.  At  full  term  the  mammary  glands 
are  evidently  prepared  for  their  function, — viz.,  furnishing  aliment  for 
the  child.  It  is  exceptional,  however,  that  lactation  is  fully  established 
at  the  time  of  parturition,  and  usually  forty-eight  hours  elapse  before 
milk  is  secreted  in  an  appreciable  quantity. 

It  is  evident  from  the  anatomy  of  the  infant  that  he  is  especially 
adapted  for  the  act  of  nursing.  The  pliable,  prehensile  lips  and  tongue, 
the  absence  of  teeth,  the  well-developed  musculature  of  the  cheeks  and 

85 


86  HYGIENE    OF    THE    FIRST    YEAR 

jaws,  the  fatty  pads  increasing  the  buccal  resistance  to  atmospheric  press- 
ure, all  go  to  form  an  incomparable  mechanism  for  grasping  the  nipple 
and  promoting  the  outflow  of  milk  by  establishing  a  vacuum.  This  the 
infant  does  instinctively. 

Of  interest  also  in  the  peculiar  adaptation  of  the  mother,  in  the 
relative  arrangement  of  the  breasts  to  the  upper  extremities  with  the 
shortened  clavicles,  in  the  conformation  of  the  breasts  with  their  soft 
and  yielding  walls  which  collapse  readily  as  the  milk  is  drawn,  in  the 
position,  size,  and  shape  of  the  nipple  with  the  many  minute  orifices 
and  richness  in  erectile  tissue;  also  in  the  manner  in  which  the  breasts 
are  filled — the  process  going  on  most  rapidly  during  nursing — and, 
finally,  in  the  sympathetic  arrangement  which  facilitates  extrusion  of 
milk  under  stimulation  of  the  infant's  lips  and  hands. 

That  no  fully  developed  milk  is  found  in  the  breasts  at  the  time  of 
birth  has  been  generally  accepted  as  conclusive  evidence  that  the  new- 
born is  in  no  immediate  need  of  food.  In  fact,  as  stated  in  a  previous 
chapter,  its  deportment,  if  undisturbed,  suggests  the  need  of  rest  dur- 
ing the  first  forty-eight  hours  of  extrauterine  existence.  This  belief  is 
so  universal  that  attempts  at  feeding  before  nature  has  furnished  the 
supply  of  milk  have  not  met  with  general  approval.  To  be  sure,  it  is 
recommended  that  the  child  be  put  to  the  breast  early,  in  the  belief  that 
the  scanty  secretion  of  colostrum  plays  some  role  in  stimulation  of  peri- 
stalsis of  the  alimentary  tract,  and  the  expulsion  of  meconium.  Proba- 
bly, by  so  doing,  the  infant  secures  a  modicum  of  the  water  so  much 
needed  at  this  time.  The  infant's  habitual  loss  in  body  weight  during 
the  first  days,  as  shown  by  tables  in  a  previous  chapter  on  growth,  has 
been  regarded  by  some  as  unnecessary.  In  fact,  it  is  claimed  to  be  un- 
fortunate as  interfering  with  the  rate  of  subsequent  growth.  On  this 
account  it  has  been  recommended  that  some  nourishment  be  substituted 
during  these  first  two  days.  It  remains  for  more  extended  clinical  ob- 
servation to  determine  the  value  of  this  procedure,  but  with  necessary 
hygienic  precaution  it  seems  permissible  to  administer  some  attenuated 
solution,  as  of  milk-sugar,  the  water  of  which,  at  least,  should  meet  a 
physiological  demand. 

The  subject  of  suckling,  proclaimed  by  many  to  be  purely  instinctive 
in  both  its  maternal  and  infantile  relations,  is  well  worthy  of  careful 
study  and  the  application  of  the  best  known  principles  of  hygiene.  Given 
normal  mothers  with  normal  infants,  the  disturbances  of  digestion,  nutri- 
tion, and  growth,  though  rare,  are  yet  sufficiently  frequent  to  raise  the 
question  of  their  etiology.  Further  than  this,  the  great  mortality  of 
infants  at  the  breast,  from  disorders  occasioned  by  improper  methods 
of  suckling,  makes  it  evident  that  instinct  is  not  a  sufficient  guide.  Rea- 
soning from  analogies  furnished  from  lower  mammalia  is  not  profitable 
in  reference  to  this  point,  since  it  would  appear  that  in  the  higher  intel- 
lectual development,  woman's  instinct  becomes  perverted  or  deranged 
^o  a  certain  extent. 

Be  that  as  it  may,  it  is  readily  susceptible  of  demonstration  that  in- 


RULES  FOR  BREAST  FEEDING  87 

telligent  control  or  supervision  of  the  act  of  suckling,  averts  or  corrects 
many  evil  effects  of  its  abuse  when  left  entirely  to  instinct.  A  few  rules 
may  be  formulated,  the  observance  of  which  is  manifestly  important  in 
the  hygiene  of  nursing. 

Rule  1. — Asepsis  must  be  observed,  since  one  of  the  commonest  causes 
of  infantile  disorders  is  infections  introduced  into  the  alimentary  tract. 
To  this  end  the  nipple  must  be  cleansed  before  and  after  nursing,  as 
it  is  well  known  that  milk  remaining  exposed  to  the  air  shortly  swarms 
with  micro-organisms,  many  of  which  are  pathogenic  when  introduced 
into  the  digestive  tract.  Even  the  milk  in  the  orifices  of  the  ducts  often 
becomes  infected;  hence  the  expression  of  a  few  drops  is  recommended 
before  the  application  of  the  child. 

Rule  2. — The  infant  should  be  put  to  the  breast  every  two  hours 
during  the  day  and  once  at  night  for  the  first  six  weeks.  From  six  weeks 
to  three  months  the  intervals  between  nursings  should  be  increased  to 
two  and  one-half  hours.  During  the  latter  part  of  this  period  the  night 
nursing  may  be  discontinued.  Between  three  and  six  months  the  interval 
should  be  increased  to  three  hours,  representing  seven  nursings  from  five 
in  the  morning  to  eleven  at  night  inclusive.  Six  nursings  a  day  should 
be  sufficient  for  a  child  at  six  months.  By  the  end  of  the  year  he  may 
be  accustomed  to  five.  If  sleeping,  he  should  be  awakened  at  the  proper 
time  for  nursing  until  the  habit  becomes  established. 

This  rule,  though  not  so  arbitrary  in  its  requirements  as  Rule  1,  should 
be  somewhat  rigidly  applied,  for,  with  few  exceptions,  nothing  is  more 
evident  than  that  disturbed  digestion,  with  all  its  train  of  evil  conse- 
quences, is  the  common  result  of  too  frequent  or  irregular  feeding.  With- 
out mentioning  the  effect  upon  lactation  of  irregularity  in  nursing,  it 
must  be  borne  in  mind  that  the  operation  of  the  digestive  function  is  a 
periodical  one,  and,  within  certain  physiological  limits,  a  matter  of  edu- 
cation and  habit,  so  that  regularity  as  to  ingestion  of  food  meets  with 
corresponding  regularity  of  the  secreting  organs.  Passing  the  feeding 
hour  induces  overingestion  from  an  overdistended  mammary  gland.  This 
undue  amount  taken  at  an  unusual  time  finds  the  digestive  fluids  unpre- 
pared ;  hence  their  incapacity  for  proper  disposition  of  the  unusual 
burden. 

The  frequency  of  nursing,  as  laid  down  in  the  rule,  is  the  result  of 
many  comparative  observations  upon  healthy  infants  and  of  the  known 
physiology  of  the  digestive  processes.  A  certain  definite  time,  as  has  been 
stated  in  a  previous  chapter,  is  necessary  to  the  physiological  disposition 
of  an  ingested  meal.  After  this  an  interval  of  rest  is  requisite  for  the 
re-establishment  of  the  function  in  its  highest  perfection.  Nothing  is 
more  abhorrent  to  nature  than  "  meals  at  all  hours."  The  practice  of 
the  mother  sleeping  with  the  babe  on  her  arm  and  quieting  his  restlessness 
throughout  the  night  by  offering  the  breast  is,  unfortunately,  too  preva- 
lent, the  result  being  that,  instead  of  receiving  one  definite  nursing,  the 
helpless  infant  is  made  the  victim  of  a  perverted  instinct,  and  sooner  or 
later  is  permanently  injured. 


88  HYGIENE    OF    THE    FIRST    YEAR 

It  is  seen  that  the  digestive  process  is  one  of  varied  stages,  each 
dealing  with  a  changed  condition  in  the  mass  of  aliment.  It  is  apparent 
from  this  last  that  the  digestive  secretions,  acting  in  sequence,  are  not 
at  all  times  suitable  for  freshly  ingested  aliment.  This  is  no  mere  theory, 
as  every  observer  well  knows  the  pernicious  results  of  too  frequent  feed- 
ing, and  probably  no  vicious  practice  presents  such  vexatious  problems. 

Rule  3. — The  time  occupied  in  nursing  and  the  quantity  ingested 
should  oe  controlled  by  the  mother.  At  first  thought  this  rule  may  seem 
impracticable,  but  a  little  reflection  will  show  that  it  is  not,  and  evidence 
is  abundant  as  to  the  necessity  for  its  observance.    Certain  it  is  that  the 


IS^s^v^v^d^i 

_  jail:;    .    "  /  ™<f&K&m?  . 

-aM 

gPHB*  .,•    ^® 

M           .    *•      -JjB 

JfT . 

***-—  fjjflj 

1 

1 

jKKS                     ^1  '{-£■'■  .-■■A 

L 

Fig.  51. — Correct  position  for  nursing. 

differences  in  the  formation  of  the  nipple  and  in  the  function  of  the 
gland  in  different  mothers,  affect  nursing  more  or  less.  There  is  a  dif- 
ference, too,  in  the  nursing  energy  of  different  infants,  so  that  one  will 
occupy  half  an  hour  in  securing  a  meal,  while  another  may  gorge  him- 
self in  ten  minutes.  The  act  of  nursing  in  its  perfection  is  the  result 
of  the  mutual  co-operation  of  mother  and  child  and  is  a  performance 
worthy  of  their  undivided  attention;  in  fact,  it  should  demand  it.  A 
child  cannot  properly  nurse  the  passive  breast  of  a  sleeping,  or  even  an 
inattentive,  mother.  In  cases  where  the  nipple  formation  is  imperfect, 
rendering  the  abstraction  of  milk  laborious  to  the  infant  or  painful  to 
the  mother,  or  where  milk  secretion  is  tardy  or  insufficient,  the  mother 


RULES  FOR  BREAST  FEEDING  89 

should  aid  and  encourage  the  babe  by  placing  herself  in  full  harmony 
with  the  pleasurable  duty  of  the  moment,  and  endeavor  to  secure  a  full 
response  to  the  stimulating  appeal  of  the  tiny  solicitor  for  a  better 
supply.  No  verbal  description  can  compass  the  art  in  which  fingers, 
arms,  bosom,  eyes,  voice,  and  the  whole  sentient  being  of  the  mother  co- 
operate with  the  infant  in  the  collection  of  his  dues  (Fig.  51). 

On  the  other  hand,  where  the  milk  gushes  through  patulous  nipples, 
or  in  the  case  of  infants  who  nurse  with  such  avidity  that  the,  process, 
from  beginning  to  completion,  resembles  a  struggle  against  suffocation, 
the  mother  should  control  the  outflow.  This  may  be  done  by  dextrous 
manipulation  of  the  nipple  between  the  fingers,  by  withdrawing  from 
the  infant's  mouth,  by  diverting  his  attention,  and  in  various  ways  pro- 
longing the  process.  It  is  safe  to  say  that  twenty  minutes  should  be 
given  to  each  nursing.  Prolonged  too  much,  the  infant  as  well  as  the 
mother  suffers  fatigue.  Interference  with  digestion  occurs  also  under 
the  principles  above  enumerated.  Too  rapid  feeding  throws  into  the 
stomach  a  large  quantity  of  food,  with  the  result  of  overdistention  and 
the  early  escape  from  the  pylorus  of  milk  insufficiently  converted.  This  is 
further  augmented  by  the  hydrostatic  pressure  of  a  superimposed  column 
filling  the  oesophagus.  Hasty  feeding  usually  means  overfeeding.  Not 
infrequently  the  stomach  resents  this  abuse  by  immediate  regurgitation 
of  a  portion  of  its  contents,  which  has  led  to  an  erroneous  belief  quite 
prevalent,  that  the  stomach  is  endowed  with  some  sentient  quality  which 
enables  it  to  reject  superfluous  aliment.  That  this  is  a  pernicious  error, 
the  frequent  occurrence  of  gastric  dilatation  and  intestinal  indigestion 
is  ample  evidence.  It  may  be  suggested  to  mothers  who  experience  diffi- 
culty in  restricting  the  overingestion  of  milk,  that  the  nursing  be  pre- 
ceded by  the  administration  of  a  little  sterilized  water,  possibly  sugar- 
of-milk  solution,  to  partly  satisfy  the  voracity  which  may  be  due  largely 
to  habit  or  thirst.  Instinct  is  no  sure  guide  as  to  the  amount  a  child 
should  nurse. 

Rule  4. — Give  water  systematically  and  freely.  The  baby 's  food, 
as  will  be  shown  later,  is  made  up  of  several  widely  different  constituents. 
Although  all  of  them  are  essential  for  perfect  nutrition,  one  or  more 
may  be  temporarily  deficient  without  immediate  perceptible  interference 
with  vital  processes.  In  fact,  one  only  must  be  present  under  all  cir- 
cumstances, and  this  is  water.  Without  water  no  digestion,  absorption, 
or  elimination  is  possible.  Water  enters  largely  into  the  composition  of 
the  infant's  food,  milk  containing  about  eighty-eight  per  cent.  It  has 
been  shown  that  water  is  essential  to  peptone  absorption,  and  many 
abnormal  and  even  pathological  conditions  result  from  an  insufficient 
supply.  The  restlessness  of  an  infant  is  frequently  only  an  expression 
of  his  thirst,  and  many  of  the  symptoms  of  hunger  are  merely  evidences 
of  a  demand  for  water.  How  often  the  pathetic  spectacle  is  witnessed 
of  forcing  unrequired,  consequently  injurious,  food  upon  an  unwilling 
stomach  in  response  to  the  infant's  appeal  for  water.  There  is  no  dif- 
ference of  opinion  in  regard  to  the  occasional  need  of  water  between 


90  HYGIENE    OF    THE    FIRST    YEAR 

nursings,  although  among  the  laity  it  is  seldom  recognized.  This  is  as 
true  in  early  as  in  later  infancy, — in  fact,  the  tendency  at  birth  to  exces- 
sive uric  acid  formation  becomes  pathologic  unless  water  be  freely  sup- 
plied to  dissolve  the  solid  crystals,  clear  out  the  renal  tubules,  and  ren- 
der the  urine  less  irritating.  Evidences  of  pain,  usually  ascribed  to 
intestinal  colic,  are  too  frequently  indicative  of  uric  acid  irritation,  and 
point  to  a  need  for  more  water.  Fortunately,  the  doping  of  the  baby 
with  carminative  teas,  for  the  supposed  intestinal  spasm,  occasionally 
fulfils  the  indication  through  the  water  of  the  decoction. 

BREAST   MILK. 

Concerning  the  composition  of  human  milk  much  has  been  written^ 
and  quoted  that  cannot  be  accepted  in  the  light  of  present  knowledge. 
Either  because  of  improved  technique   or  from  a  greater  number   of 
observations,  recent  analyses  do  not  corroborate  the  findings  of  many 
early  chemists. 

Milk  is  an  emulsion  of  innumerable  minute  globules  of  fat  floating 
in  plasma.  Its  white  color  is  produced,  as  in  other  emulsions,  by  reflec- 
tion from  the  surface  of  the  numerous  cells. 

As  it  is  a  perfect  emulsion,  the  fat  globules  remain  distinct.  The 
older  opinion,  that  a  thin  membrane  of  albuminous  material'  surrounded 
each  cell,  is  no  longer  generally  held.  From  experiments,  Quincke  has 
proved  that  each  fat  globule,  by  molecular  attraction,  is  surrounded  by 
a  more  closely  adherent  layer  of  milk  plasma,  and  not  by  a  membrane. 
Among  the  globules  are  smaller  particles  of  proteid  matter.  The  exami- 
nation of  milk  from  a  large  number  of  women  gives  the  specific  gravity 
as  1.028  to  1.034. 

All  the  five  principal  classes  of  foods  are  found  in  milk, — viz.,  water, 
fats,  proteids  (caseinogen,  lactalbumin,  lactoglobulin),  carbohydrates, 
and  salts,  besides  extractives  and  gases ;  also  lecithin,  cholesterin,  citric 
acid,  and  other  substances  in  varying  proportions. 

That  these  classes  of  foods  are  essential  to  normal  nutrition  and 
growth  is  susceptible  of  demonstration,  both  by  well-known  principles 
of  physiology,  and  by  daily  clinical  observation.  It  is  probable  that  per- 
fect metabolism  is  dependent  upon  the  presence  of  all  these  food  prin- 
ciples, although  life  may  be  maintained  for  a  longer  or  shorter  time  if 
one  or  more  be  omitted  from  the  diet  (always  excepting  water).  Thus 
an  infant  may  exist  for  a  time  on  water  and  carbohydrates,  as  solution 
of  sugar  of  milk,  or  on  water  and  proteids,  or  on  water  and  salts;  the 
result,  however,  invariably  showing  in  impaired  nutrition.  This  is  so 
well  recognized  clinically  that  the  absence  of  one  or  more  of  these  essen- 
tial constituents  is  not  infrequently  determined  by  the  condition  of  the 
infant. 

A  symmetrical  development  requires  not  only  the  presence  of  all 
the  constituents,  but  that  they  should  maintain  a  certain  definite  quan- 
titative ratio. 

The  proteids  furnish  the  only  source  from  which  the  tissues  obtain 


COMPOSITION    OF    BREAST    MILK  91 

nitrogen,  without  which  no  protoplasm  can  exist,  nor  cell  life  be  possible. 
A  deficiency  invariably  results  in  retardation  of  development.  Insuffi- 
cient nitrogen  means  diminished  metabolism,  interrupted  gain  in  bods- 
weight,  lessened  muscular  force,  anaemia  with  the  weakened  heart's 
action  and  dyspnoea,  arrested  secretions,  and  all  the  familiar  evid<-n<-<-s 
of  lowered  nutrition. 

It  was  formerly  taught  that  the  purpose  of  fats  was  to  produce  heat, 
a  very  important  function,  as  a  certain  degree  of  heat  is  necessary  for 
tissue  metamorphosis.  It  can  be  demonstrated  that  fat  plays  a  double 
role  and  that,  in  addition  to  the  maintenance  of  body  heat,  it  aids  the 
proteids  in  cell  development,  especially  in  the  formation  of  bone  and 
nerve  tissue.  Besides  its  synergistic  agency  in  increasing  the  activity 
of  the  proteids,  it  serves  another  purpose  by  promoting  absorption  of 
the  salts  from  the  intestines.  It  also  maintains  the  healthy  function  of 
the  lower  bowel  by  promoting  the  passage  of  the  fasces,  of  which  it  nor- 
mally forms  about  ten  per  cent.  A  deficiency  of  fat  produces  results 
such  as  always  follow  diminished  metabolism,  and  frequently  a  group 
of  signs  of  impaired  nutrition  so  uniform  as  to  have  been  classified  under 
the  term  rhachitis. 

The  carbohydrates,  in  the  form  of  milk-sugar,  have  occasioned  no 
little  discussion  as  to  their  value  as  compared  with  the  preceding  class. 
Some  authorities  place  them  third  in  importance ;  von  Noorden  and  Kay- 
ser,  however,  have  found  that  carbohydrates  are  of  greater  value  as 
proteid  sparers  than  are  fats,  as  the  latter  cannot  be  substituted  for  their 
caloric  equivalent  of  carbohydrates  without  loss  of  proteids  occurring. 
It  has  long  been  known  that  sugar  increases  the  formation  and  depo- 
sition of  fat,  babies  frequently  showing  a  remarkable  plumpness,  even 
though  fat  and  proteids  be  lacking  in  the  food. 

The  fourth  group — the  salts — consisting  chiefly  of  calcium  phosphate ; 
potassium  carbonate,  sulphate,  and  chloride ;  sodium  chloride,  and  a  trace 
of  iron,  forms  a  small  but  fairly  uniform  and  very  important  percentage 
of  the  total  constituents.  As  a  result  of  his  analyses,  Bunge  claims  that, 
with  two  exceptions,  the  percentage  of  salts  in  milk  corresponds  quite 
closely  with  the  salts  in  the  tissues  of  the  nursling. 

A  very  essential  and  comparatively  abundant  salt  is  calcium  phos- 
phate, which  is  required  for  bone  formation.  Lime  is  taken  in  and  as- 
similated by  the  organism  in  the  form  of  organic  compounds  with  the 
proteids. 

The  potassium  salts,  also  abundant,  are  needed  in  the  formation  of 
muscular  tissue  and  in  the  red  blood-cell.  A  significant  fact  is  the  greater 
amount  of  potassium  and  lesser  amount  of  sodium  salts  in  milk  than  in 
the  tissue  of  the  infant.  During  postnatal  growth  there  is  a  relative 
increase  in  the  muscles  which  are  rich  in  potassium,  and  a  diminution 
in  the  cartilages  which  are  rich  in  sodium. 

Sodium  chloride,  as  is  well  known,  performs  an  important  office  in 
digestion,  for,  during  the  passage  through  the  body,  it  facilitates  the 
absorption  of  proteid  food  and  increases  tissue  metabolism. 


92  HYGIENE    OF    THE    FIRST    YEAR 

Wittmaack  and  Siegfried,  from  their  analyses,  found  that  nucleon 
or  phospho-carnic  acid  accounts  for  41.5  per  cent,  of  the  phosphorus  in 
human  milk.  Practically  all  the  phosphorus  is  in  organic  combination 
(nucleon  and  caseinogen). 

The  iron,  so  essential  to  the  formation  of  blood,  and,  to  a  less  degree, 
of  the  other  liquids  of  the  body,  is  present  in  mother 's  milk  in  extremely 
small  quantity.  The  percentage  is  only  one-sixth  of  that  found  in  fetal 
tissues.  Infants  enter  the  world  with  a  store  of  iron  in  the  liver,  and 
to  some  extent  in  the  spleen,  which  lasts  them  until  they  are  able  to  take 
food  other  than  milk. 

As  stated,  the  salts  vary  but  little  in  percentage,  but  should  a  defi- 
ciency be  present,  the  osseous,  nervous,  digestive,  muscular,  or  circulatory 
system,  would  suffer  the  sooner,  according  to  the  individual  constituents 
most  at  fault. 

Were  the  other  ingredients  present  in  normal  mother 's  milk  in  proper 
proportions,  the  absence  of  water  would  render  them  valueless  for  food. 
It  is  only  in  a  state  of  solution  that  most  of  these  substances  can  undergo 
digestion  in  the  intestines  of  the  infant,  or  absorption  through  the  villi. 
The  normal  secretions  are  relatively  scant  in  proportion  to  the  enormous 
work  accomplished  during  the  growing  period.  Hence  the  necessity  for 
water  at  all  stages. 

The  first  group — the  proteids,  of  which  there  are  four  or  more — is 
chiefly  represented  by  three  albuminous  substances,  differing  in  their 
physical  properties.  An  important  member  of  this  group  is  casein,  which 
was  formerly  thought  to  be  derived  from  caseinogen  by  a  double  process, 
first,  through  the  action  of  the  rennin  enzyme,  being  changed  to  soluble 
casein ;  and,  second,  by  the  action  of  calcium  salt,  precipitated  in  curd 
as  a  caseate  of  lime.  Van  Slyke  and  Hart  have  shown  that  this  proteid 
exists  in  the  milk  as  calcium  casein,  which  is  changed  by  rennet  into 
calcium  paracasein.  The  action  of  small  amounts  of  acid  upon  these 
two  bodies  produces  free  casein  and  free  paracasein.  With  larger 
amounts  of  acid  definite  salts  are  formed,  as  lactate  or  hydrochloride  of 
casein  and  paracasein  respectively. 

The  other  proteids,  lactalbumin,  lactoglobulin,  etc.,  are  not  precipi- 
tated by  rennin  or  acids,  but  coagulate  with  heat  at  from  158°  F. 
(70°  C.)  to  167°  F.  (75°  C),  and  are  known  as  the  soluble  or  whey 
proteids.  Lactalbumin  differs  from  casein  also  in  that  it  contains  sul- 
phur but  not  phosphorus.  It  is  not  identical  with  serum  albumin,  though 
it  resembles  it  in  many  respects.  Lactoglobulin  is  ordinarily  present  in 
very  small  amounts. 

The  carbohydrates  are  found  in  the  form  of  lactose,  a  sugar  peculiar 
to  milk,  differing  from  other  sugars  in  its  inferior  solubility  m  water, 
and  lack  of  sweetness  to  taste.  It  also  resists  the  tendency  to  alcoholic 
fermentation,  but  readily  yields  lactic  acid  when  attacked  by  the  bac- 
terium lactis  asrogones  of  Escherich.  Hiippe's  bacillus,  also  the  bacillus 
coli  communis  and  many  others,  have  this  property  of  causing  lactic  acid 
fermentation  and  precipitation  of  casein  in  the  form  of  casein  or  para- 


COMPOSITION    OF    BREAST    MILK  93 

casein  lactate.  These  lactates  are  susceptible  to  the  action  of  pepsin 
and  are  refractory  to  putrefactive  forms  of  bacteria. 

Another  carbohydrate  has  been  described  as  existing  in  milk,  named 
variously  by  different  observers  as  "animal  gum,"  "dextrin,"  "animal 
amyloid."  Milk  also  contains  its  own  specific  enzymes  which,  as  shown 
by  Babcock  and  Russell,  are  capable  of  digesting  the  proteids,  although 
at  a  very  slow  rate  as  demonstrated  outside  of  the  body. 

The  following  table,  from  the  analyses  of  Harrington  and  Kennicutt, 
is  quoted  by  Rotch. 

MINERAL    CONSTITUENTS   IN   HUMAN    MILK. 

Calcium  phosphate   23.87 

Calcium    silicate     1.27 

Calcium  sulphate    2.25 

Calcium  carbonate    2.85 

Magnesium    carbonate     3.77 

Potassium  carbonate    23.47 

Potassium    sulphate     8.33 

Potassium    chloride    12.05 

Sodium  chloride    21.77 

Iron    oxide    alumina    0.37 


100.00 

As  before  stated,  normal  milk  contains  these  five  constituents,  which 
maintain  a  fairly  constant  percentage  relationship.  Frequent  variations 
are,  however,  observed  in  normal  milk  as  in  different  mothers,  or  in  the 
same  mother  at  different  times,  or  in  the  same  mother  in  different  breasts, 
or,  as  is  well  known,  in  the  same  breast  at  the  same  milking,  drawn  at 
different  times,  as  fore,  middle,  and  last  milk. 

Of  these  constituents  the  percentage  of  fat  is  subject  to  the  widest 
variation;  next  the  proteids, — the  carbohydrates  and  salts  rarely  show- 
ing much  change.  These  variations  need  not  be  considered  as  indications 
of  abnormality,  the  only  criterion  being  their  effect  upon  the  child.  An 
infant  at  the  breast,  digesting  well  and  gaining  in  weight  and  strength, 
is  ingesting  normal  milk,  regardless  of  what  the  analysis  may  show. 

The  personal  equation — the  capacity  of  any  particular  infant  to 
digest  the  varying  constituents — must  always  be  recognized  as  an  un- 
known quantity.  It  is  a  fact  of  common  clinical  observation  that  the 
breast,  at  which  one  infant  thrives,  may  not  meet  the  requirements  of 
another  child  of  the  same  age. 

As  seen  from  the  foregoing,  it  is  evident  that  repeated  analyses  are 
necessary  to  determine  the  average  constituents  of  one  woman's  milk. 

The  careful  work  of  the  Adriances  has  illustrated  the  varying  quan- 
tities of  these  constituents  at  different  stages  of  lactation  as  follows : 

AVERAGE   PERCENTAGES   OF    HUMAN    MILK. 

Proteids    1-2 

Fat    3-4 

Lactose    6-7 

Salts    0.1-0.2 

Water     87-90 


94  HYGIENE    OF    THE    FIRST    YEAR 

Average  specific  gravity,  1.028  to  1.034;  reaction,  alkaline.  Addi- 
tional significance  attaches  to  their  conclusions  from  the  advantages  they 
enjoyed  of  observing  a  large  number  of  healthy  women  during  long 
periods.  A  review  of  their  observations  leads  to  the  following  conclu- 
sions : 

(1)  The  fat  shows  no  constant  changes  during  lactation.  Its  most 
marked  characteristic  is  its  variability. 

(2)  The  carbohydrates,  on  the  second  day  of  lactation,  are  low,  but 
rise  rapidly  during  the  first  few  days.  This  increase  continues,  but  less 
rapidly  up  to  the  end  of  lactation. 

(3)  The  proteids  pursue  a  course  the  reverse  of  the  carbohydrates. 

(4)  The  salts  diminish  similarly  to  the  proteids. 

(5)  The  colostrum  period  has  low  carbohydrates,  with  a  tendency  to 
increase  rapidly,  and  high  proteids  and  salts,  with  a  tendency  to  decrease 
rapidly. 

(6)  The  milk  of  the  later  months  of  lactation  shows  a  deficiency  in 
proteids,  ash,  and  total  solids. 

More  recently  human  milk,  by  the  phenolphthalein  test,  has  been 
shown  to  be  feebly  acid. 

The  milk  of  the  first  ten  or  fourteen  days  possesses  peculiarities  that 
are  not  normally  found  at  any  subsequent  period  of  lactation,  and  is 
known  as  colostrum.     The  characteristics  of  the  milk  of  this  period  are : 

(1)  The  presence  of  colostrum  corpuscles.  Normally  these  persist 
in  the  milk  from  seven  to  ten  days.  These  are  believed  by  Schafer  to 
be  leucocytes  which  have  migrated  through  the  connective  tissue.  In 
the  warm  stage  they  show  amoeboid  motion. 

(2)  The  laxative  effect  upon  the  infant. 

(3)  The  yellow  color  of  the  milk. 

(4)  Chemical  characteristics ;  the  fat  may  be  very  high  or  very 
low:  the  sugar  (in  the  form  of  dextrose)  is  lower  on  the  second  day  than 
at  any  other  time,  but  increases  rapidly  up  to  the  end  of  the  second 
week ;  the  proteids  pursue  the  opposite  course,  being  the  highest  on  the 
second  day  but  falling  rapidly  the  first  few  days;  the  salts,  like  the 
proteids,  are  higher  than  subsequently.  The  most  interesting  feature 
of  the  above  is  seen  in  the  forms  of  the  sugar  and  proteids  during  the 
colostrum  period.  These  proteids  are  the  soluble  albumins  and  globulins 
which  are  readily  absorbed  by  the  infant  without  gastric  digestion. 
Colostrum  coagulates  with  heat.  Later,  the  soluble  proteids  and  dextrose 
are  largely  replaced  by  casein  and  lactose  (milk  sugar)  and  normal 
lactation  is  established. 

Having  considered  normal  milk  it  will  be  well  to  discuss  the  changes 
which  constitute  departures  from  the  normal,  as  seen  by  their  effects 
upon  the  infant's  nutrition.  Before  entering  upon  this  subject  the 
physiological  process  by  which  the  milk  is  produced  should  be  considered 
briefly,  in  order  to  better  appreciate  some  of  the  influences  that  affect 
these  changes.  A  peculiarity  of  the  function  of  the  mammary  gland  is 
that  it  persists  during  a  more  or  less  definite  time  and  then  subsides. 


MILK    PRODUCTION  95 

Exceptions  are  seen  in  some  cases  of  prolonged  lactation,  and  in  curious 
instances  in  which  the  function  was  established  in  women  who  had  never' 
coneeived,  under  stimulation  of  the  nipple  by  sucking,  a  point  of  clinical 
value. 

Without  taking  time  to  review  the  structure  of  the  gland,  attention 
is  called  to  the  fact  that  the  alveoli  are  lined  with  columnar  epithelium, 
and  it  is  by  means  of  these  cells  that  this  composite  emulsion  is  produced. 

The  exact  mode  of  its  production  from  the  circulating  fluids  has  been 
a  subject  of  much  discussion  and  extended  research.  The  older  belief 
that  the  cells  of  the  glands  operated  as  a  sort  of  filter,  the  milk  being 
derived  directly  from  the  blood,  has  been  rejected  as  unscientific.  To- 
day three  theories  claim  attention. 

Stated  briefly,  the  first  explains  the  production  of  fat  by  an  actual 
breaking  down  of  the  lining  cells — a  fatty  degeneration — a  process 
which  it  is  estimated  would  require  the  renewal  of  the  epithelium  of  the 
alveoli  at  least  five  times  in  the  twenty-four  hours.  This  is  held  by  some 
to  be  preposterous.  The  second  theory  is  a  modification  of  the  first,  as 
only  the  free  ends  of  the  cells,  after  a  stage  of  increased  activity,  appear 
to  break  down,  liberating  their  products  of  metabolism,  the  fixed  ends 
with  the  nuclei  remaining  to  renew  the  process.  The  third  attributes 
to  the  cells  of  the  mammary  gland,  through  the  agency  of  the  proto- 
plasm, an  energy  analogous  to  other  secreting  structures, — viz.,  that 
they  have  the  power  of  elaborating  from  the  fluids  a  secretion  peculiar 
to  themselves,  cell  destruction  being  no  more  necessary  than  in  other 
secreting  glands.  A  more  exact  knowledge  on  this  subject  would  be 
valuable  in  its  bearing  upon  the  subject  of  changing  the  constituents 
of  the  milk  by  physiological  methods,  as  feeding,  etc.,  a  matter  which 
has  hitherto  been  determined  exclusively  by  clinical  observation  and 
experiment.  Were  the  glands  mere  filters,  as  was  formerly  taught,  it 
is  reasonable  to  suppose  that  the  quality  of  their  products  would  par- 
take of  the  nature  of  the  blood  constituents,  and  that  changes  in  the 
latter  would  produce  corresponding  changes  in  the  milk,  a  result  which 
repeated  observations  have  disproved. 

No  secretory  nerves  have  yet  been  demonstrated  in  the  mammary 
gland,  but  were  clinical  data  wanting  analogy  would  compel  the  accept- 
ance of  the  hypothesis  of  nerve  influence  and  control  in  the  secretion  of 
milk,  probably  through  the  cranial  and  sympathetic  nerves.  It  is  a  fact 
of  such  common  observation  that  mental  conditions  influence  the  milk 
supply,  that  no  teacher  denies  it. 


CHAPTER   VII 
HYGIENE   OF    LACTATION 

QUANTITY   OF    MILK 

Milk  secretion  is  subject  to  variations  in  quantity  as  well  as  in 
quality.  In  the  majority  of  cases  it  is  regulated  to  meet  the  require- 
ments of  the  infant,  although  instances  are  not  uncommon  in  which  the 
quantity  is  insufficient.  On  the  other  hand,  it  frequently  occurs  that 
the  mother  may  successfully  nurse  two  infants,  as  in  the  case  of  twins,  or 
in  wet-nursing  in  foundlings'  homes,  etc.  From  this  it  may  be  inferred 
that  in  some  mysterious  way,  to  a  limited  extent,  the  supply  is  regulated 
by  the  demand. 

Some  interesting  observations  have  been  made  to  determine  the  quan- 
tity of  milk  secreted  during  normal  lactation.  By  careful  weighing  of 
the  child  immediately  before  and  after  nursing  the  amount  taken  can  be 
easily  ascertained.  This  work  has  been  thoroughly  done  by  Hahner, 
Laure,  Ahlfeld,  and  others,  with  the  following  results  as  quoted  by  Holt : 

AVERAGE   QUANTITY   OP   MILK   SECRETED   DAILY   UNDER   NORMAL    CONDITIONS 

Ounces.  Grammes. 

At  the  end  of  first  week   10-15  (300-  500) 

During   second   week    13-18  (400-  550) 

During  third  week   14-24  (430-  720) 

During  fourth  week   16-26  (500-  800) 

From  fifth  to  thirteenth  week   20-34  (600-1030) 

From  fourth  to  sixth  month 24-38  (720-1150) 

From  sixth  to  ninth  month   30-40  (900-1220) 

It  will  be  observed  by  comparing  the  above  table  with  those  in  Chap- 
ter II  that  the  increase  in  quantity  of  milk  ingested  corresponds 
quite  closely  with  the  increase  in  stomach  capacity  and  body  weight, 
and  that  this  increase  in  quantity  is  most  rapid  during  the  first  three 
months,  to  meet  the  increasing  demand  for  nutrition  during  this  period. 
Further  analysis  of  the  reports  of  these  cases  shows  that  the  larger 
infants  took,  not  only  absolutely  but  relatively,  more  than  the  smaller. 
As  before  noted,  the  growth  of  large  babies  is  relatively  more  rapid 
than  that  of  smaller  ones.  Attention  is  again  called  to  the  wonderful 
automatic  adjustment  of  the  quantity  of  milk  to  the  needs  of  the  child. 
It  is  believed  that  the  surplus,  if  not  drawn,  is  reabsorbed. 

It  is  a  question  whether  the  daily  quantity  of  milk  can  be  increased 
by  any  medicinal  agent.  It  is  well  known,  however,  that  the  mammary 
secretion,  both  as  to  quantity  and  composition,  is  quite  sensitive  to  many 
influences.  A  so-called  "dry  diet,"  in  which  there  is  a  deficiency  of 
water,  usually  diminishes  the  secretion,  while,  on  the  other  hand,  it  may 
96 


CONDITIONS    INFLUENCING    BREAST    MILK  97 

be  increased  by  a  liberal  allowance  of  water,  milk,  cocoa,  beer,  and  other 

fluids. 

Attention  is  again  directed  to  the  mental  attitude  of  the  mother 
during  nursing  as  influencing  the  quantity  of  milk.  It  must  not  be 
forgotten,  however,  that  overanxiety  to  produce  may  defeat  its  object. 

Loss  of  fluids  from  any  cause — as  copious  perspiration,  menstrua- 
tion, or  diarrhoea — may  lessen  the  amount. 

The  secretion  of  milk,  when  scanty,  may  be  increased  by  any  agency 
that  increases  normal  metabolism — as  diet,  exercise,  massage,  electricity, 
fresh  air,  sunlight,  congenial  surroundings,  freedom  from  discomfort, 
and  an  equable  temperament.  Sudden  emotion — as  grief,  anxiety, 
anger,  fear,  or  anything  that  produces  shock  or  profoundly  impresses 
the  nervous  system — may  not  only  diminish  the  secretion,  but  occasion- 
ally may  cause  total  suppression.  It  is  suggested  that  regularity  be  ob- 
served in  putting  the  child  to  the  breast,  even  though  there  be  little 
evidence  of  milk,  as  the  secretion  is  undoubtedly  promoted  by  the  act  of 
nursing.  A  reasonable  analogy  suggests  the  use  of  cow's  or  ewe's  udder 
as  a  food  for  its  galactagogue  effect  where  milk  secretion  is  scanty. 

The  frequent  disturbances  of  digestion  and  nutrition  in  the  nursling 
have  led  to  much  study,  not  only  concerning  the  qualitative  changes  in 
his  food,  but  also  as  to  their  causes. 

It  is  accepted  that  the  constituents  of  milk  may  be  influenced  by 
variations  in  the  hygiene,  especially  in  the  diet  of  the  mother.  The 
former  belief  that  the  fat  of  the  milk  was  increased  by  the  fat  ingested, 
has  been  repeatedly  disproved  by  actual  experiment,  although  Winter- 
nitz  claims  to  have  demonstrated  the  contrary  in  lower  animals.  It 
is  believed  to-day  that  the  proportion  of  fat  in  the  milk  depends 
largely  upon  the  amount  of  proteid  in  the  mother's  food,  increase  or 
diminution  in  the  latter  causing  a  like  change  in  the  former.  This  rela- 
tion of  proteids  in  the  food  to  fats  in  the  milk  is  a  matter  of  daily 
observation.  A  mere  ingestion  of  albuminoids,  however,  is  not  sufficient 
to  produce  a  "rich  milk,"  since  thorough  digestion  and  assimilation 
are  essential  to  fat  elaboration.  Fat  may  be  scanty  in  the  milk,  not 
only  from  an  insufficiently  nitrogenous  diet,  but  also  as  a  result  of 
excess  of  fats  in  the  food.  Examples  are  not  wanting  of  mothers  who, 
in  their  efforts  to  enrich  their  milk,  defeat  this  object  by  inordinate 
ingestion  of  cream. 

The  familiar  spectacle  of  a  rhachitic  infant  at  the  breast  of  the  mother, 
whose  diet  consists  largely  of  amylaceous  and  saccharine  constituents, 
with  a  milk  of  a  high  specific  gravity  and  low  fats,  emphasizes  the  impor- 
tance of  a  knowledge  of  fat  production.  The  substitution  in  this  case  of 
a  diet  of  eggs  for  breakfast,  meat  for  dinner  and  supper,  with  a  cup 
of  beef  broth  between  times,  and  a  limited  supply  of  vegetables  and 
sweets,  will  frequently  show  an  increased  percentage  of  fat  in  the  milk, 
with  subsequent  improvement  in  the  nutrition  of  the  child. 

It  occasionally  occurs  that  the  infant  shows  the  effects  of  excessive 
fat  in  the  so-called  fatty  diarrhoeas,  in  which  fat  is  seen  in  the  diapers 

7 


98  HYGIENE    OF    LACTATION 

in  glistening  masses  or  floating  as  a  pellicle  on  the  surface  of  the  water. 
Again,  in  the  spitting  babies  who  regurgitate  their  food  shortly  after 
nursing,  analysis  of  the  mother's  milk  shows  sometimes  as  high  as  nine 
per  cent,  of  fat.  In  such  cases  meats  should  be  restricted  and  vegetables 
and  breadstuffs  encouraged  in  the  mother's  diet.t  Excess  of  fat  in  the 
diaper  of  a  baby  who  shows  no  other  signs  of  indigestion  need  not  be 
regarded  as  pathological. 

The  proteids  are  rarely  low,  except  in  cases  of  exhaustion  or  debility, 
as  from  sickness  or  insufficient  food.  In  this  condition  the  milk  is  poor 
and  watery,  there  being  a  deficiency  in  all  the  solids.  In  such  cases  the 
hygiene  of  the  mother  requires  a  liberal  diet  with  all  the  accessories  for 
the  improvement  of  her  general  nutrition.  Here  nitrogenous  foods  are 
necessary  to  increase  proteids  in  the  milk.  It  may  occur  that  the 
mother's  milk,  in  cases  of  debility,  shows  an  excess  of  proteids  with  a 
deficiency  of  other  constituents,  the  debilitated  infant  exhibiting  evi- 
dences of  indigestion  by  constipation  or  diarrhoea  and  vomiting. 

Excessive  proteids  may  appear  also  in  the  overfed  mother  of  seden- 
tary habits,  for  whom  exercise  in  the  open  air  must  be  prescribed,  with 
reduction  of  diet.  Idleness  and  discontent  may  be  replaced  by  congenial 
occupation,  to  the  improvement  of  the  milk  in  this  respect.  The  relief 
of  constipation  or  the  alleviation  of  any  bodily  discomfort  taay  alone  be 
sufficient. 

Sudden  disturbances  in  the  digestion  of  a  healthy  nursling  leads  the 
physician  at  times  to  startling  conclusions  in  his  search  for  their  etiology. 
Violent  agitation  of  the  nervous  system  of  the  mother  may  change  the 
quality  of  the  lacteal  secretion  almost  instantly:  the  milk  quite  fre- 
quently, under  these  circumstances,  resembling  colostrum  in  its  changed 
proteids,  low  fat,  and  colostrum  corpuscles.  Instances  are  known  where 
convulsions  and  even  death  to  the  nursing  infant  have  followed. 

The  analysis  of  the  mother's  milk  frequently  leads  to  the  cause  of 
the  indigestion  of  the  infant.  The  secretion  of  colostrum  milk  has 
been  known  to  follow  undue  fatigue,  excitement,  anger,  grief,  coitus, 
also  menstruation  and  conception.  In  fact,  disturbances  of  digestion  in 
the  infant  are  frequently  the  first  intimation  of  pregnancy  in  the  mother. 
In  the  event  of  these  disturbances,  and  should  analysis  of  the  milk  show 
colostrum,  the  child  should  be  removed  from  the  breast  until  (excepting 
in  pregnancy)  the  secretion  approaches  the  normal.  Meanwhile  the 
breasts  should  be  emptied  regularly  by  the  pump. 

Both  the  quantity  and  quality  of  the  milk  is  influenced  by  the  fre- 
quency of  nursing.  Poor  milk  usually  results  from  prolonged  or  irregu- 
lar intervals  in  nursing.  The  more  frequently  the  breasts  are  emptied 
the  higher  will  be  the  percentage  of.  solids,  especially  the  proteids.  The 
infant,  restless  from  indigestion  induced  by  excess  of  proteids,  is  unfor- 
tunately given  the  nipple  at  short  intervals  to  quiet  him.  The  result  is 
increased  indigestibility  of  the  milk  from  greater  excess  of  proteids. 
"What  is  needed  is  water  for  his  thirst,  rest  for  his  stomach,  and  rest  for 
the  mammary  glands. 


METHODS   OF    CHANGING    THE    COMPOSITION  99 

The  following  from  Rotch  may  best  express  a  summary  of  the  means 
at  command  for  regulating  the  composition  of  mother's  milk: 
The  percentage  of  proteid  is  increased  by 

Increased  frequency  of  nursing. 

Increased  liberality  of  proteid  food. 

Insufficient  exercise. 
The  percentage  of  proteid  may  be  diminished  by 

Diminished  frequency  in  suckling. 

Diminished  proteid  food. 

Increased  exercise. 
The  percentage  of  fat  is  increased  by 

Increased  proteid  diet. 
The  percentage  of  fat  is  diminished  by 

Deficiency  of  proteid  food. 

Excess  of  fatty  foods. 

Fasting. 
The  percentage  of  water  is  increased  by 

Increased  fluid  diet. 
The  percentage  of  water  is  diminished  by 

Saline  cathartics. 

Diminished  fluid  diet. 
As  previously  stated,  the  percentages  of  sugar  and  ash  vary  but  little. 


CHAPTER   VIII 
MILK    ANALYSIS 

DETERMINATION   OF    FAT 

The  relationship  of  the  quality  of  the  milk  to  the  nutrition  and  well- 
being  of  the  infant  is  a  subject  of  ever-growing  interest.  The  more 
lactation  is  studied,  the  greater  significance  attaches  to  its  disturbances. 
It  has  been  generally  recognized  that  the  relation  was  a  causative  one,  and 
such  expressions  as  "milk  not  agreeing  with  the  baby"  have  in  a  vague 
way  expressed  the  idea.  Failures  in  the  nutrition  of  infants  were  ex- 
plained upon  the  hypothesis  that  some  constituent  was  wanting  or  in 
excess  in  the  mother's  milk.  Since  no  verification  of  this  supposition 
was  formerly  practicable,  even  possible,  no  satisfactory  corrective 
measures  could  be  undertaken.  In  other  words,  the  determination 
of  the  causes  of  digestive  or  nutritional  disturbances  amounted  to  little 
more  than  guess-work.  It  is  true  that  careful  chemical  analyses  were 
occasionally  made,  but  these  were  so  infrequent  as  to  be  of  little  value 
from  the  paucity  of  data  thus  obtained. 

The  relative  quantity  of  fat  was  early  recognized  as  important,  and 
frequent  attempts  at  its  determination  for  clinical  purposes  were  made. 
It  was  not  until  the  importance  of  the  relation  of  fat  to  specific  gravity, 
in  estimating  total  solids,  was  appreciated  that  efforts  at  milk  exam- 
ination began  to  assume  practical  value.  The  method,  in  general  prac- 
tice, of  determining  the  percentage  of  fat,  consists  in  allowing  a  sample 
of  the  milk  to  stand  for  a  certain  time  at  a  given  temperature  until 
the  line  of  demarcation  between  cream  and  milk  is  sharply  defined.  The 
percentage  of  fat  is  to  cream  as  three  to  five. 

A  number  of  devices  for  the  determination  of  fat  percentage  have 
been  employed,  among  which  may  be  mentioned  Holt's  and  Chevalier's 
creamometers,  Soxhlet's  areometer,  Feser's  laetoscope,  Marchand's  tube, 
the  lactocrit  of  De  Laval,  and  Babcock's,  also  Leffman  and  Beam's 
methods.  Several  more  elaborate  chemical  methods  have  been  omitted 
as  impracticable  for  the  busy  practitioner.  Of  the  many  devices  four 
only  will  be  described,  the  others  being  various  modifications  of  the  four 
principles  therein  employed. 

(1)  The  gravity  process  employed  by  Holt. 

(2)  The  optical  test  of  Feser. 

(3)  The  action  of  reagents  as  shown  by  Marchand. 

(4)  The  combined  action  of  reagents  and  centrifugation  as  employed 
by  Babcock  and  by  Leffman  and  Beam. 

Holt's  apparatus  for  this  purpose  consists  of  a  slender  glass  cylinder, 
graduated  to  a  hundred  divisions  (Fig.  52).    This  cylinder  is  filled  to  the 
100 


DETERMINATION    OF    PAT 


101 


zero  mark  and  allowed  to  stand  at  a  temperature  of  70°  F.  (21°  C.)  for 
twenty-four  hours,  or  until  the  cream  line  is  sharply  drawn,  when  the 
percentage  may  be  read  from  the  graduations  on  the  glass. 

Feser's  lactoscope  consists  of  a  slender  glass  cylinder,  resting  on  a 
foot  piece  containing  a  short  porcelain  column  projecting  upwards  from 
the  bottom  (Fig.  53).  This  column  is  marked  with  black  transverse 
lines.  The  test  is  applied  by  introducing,  by  means  of  the  pipette 
shown  in  the  figure,  a  given  quantity  of  milk,  which  renders  the  central 
column  invisible.  This  milk  is  gradually  diluted  with  pure  water,  with 
frequent  shaking  to  secure  thorough  admixture.  The  process  is  con- 
tinued until  a  degree  of  attenuation  is  reached  sufficient  to  brin^  into 
view  the  striae  on  the  central  column.  The  surface  of  the  cylinder  is  so 
graduated  that  the  quantity  of  the  mixture  is  made  to  express  the  per- 
centage of  fat  in  the  sample. 

In  Marchand's  method  a  graduated  glass  tube  is  employed  (Fig.  54). 
Pour  in  5  C.c.  of  milk  and  a  drop  of  caustic  soda  solution ;    add  5  C.c. 


D 


Fig.  52.— Holt's  creamometer. 


Fig.  53.— Feser's  lactoscope. 


Fig.  54.— Marchand's  tube. 


of  ether  and  shake  the  tube  until  the  fat  is  extracted.  On  adding  abso- 
lute alcohol  and  warming,  the  fat  rises  and  can  be  calculated  from  the 
depth  of  the  layer  in  the  tube. 

In  the  Babcock  method,  as  well  as  in  that  of  Leffman  and  Beam,  the 
milk  is  acidified  in  order  that  the  proteids  may  be  changed  to  soluble 
acid  albumin,  which  offers  less  resistance  to  the  rising  and  aggregation 
of  the  fat  globules.  This  is  done  in  a  peculiarly  constructed  bottle, 
having  a  long,  slender,  graduated  neck  (Fig.  55)'. 

The  bottle  is  then  placed  in  a  centrifugal  machine  (Fig.  56)  and 
rotated  from  two  to  five  minutes,  the  time  depending  upon  the  speed 
of  rotation,  when  the  separated  fat  appears  as  a  distinct  layer  in  the 
graduated  neck  where  the  percentage  is  easily  read. 


102 


MILK   ANALYSIS 


In  the  Babcock  method  only  sulphuric  acid  is  employed,  as  follows: 
17.5  C.c.  of  milk  is  poured  into  the  bottle  through  a  slender  pipette,  care 
being  taken  not  to  smear  the  neck,  then  17.6  C.c.  of  strong  commercial 
sulphuric  acid  (specific  gravity  1.82)  is  slowly  added;  at  the  same  time 
the  test-bottle  is  given  a  gyratory  motion  to  facilitate  admixture  without 
too  sudden  coagulation.  The  bottle  thus  filled  nearly  to  the  shoulder  is 
placed  in  a  centrifuge  and  revolved  for  five  minutes  with  the  speed  of, 
at  least,  1000.  Sufficient  boiling  water  is  then  introduced  to  fill  the 
bottle  well  up  into  the  graduated  neck,  when  it  is  again  centrifugated 
for  one  minute,  after  which  the  percentage  of  the  supernatant  fat  may 
be  read  off. 

The  principle  of  the  Leffman  and  Beam  method  is  similar.  Their 
test-bottles  (Fig.  57)  have  a  capacity  of  about  30  C.c.  and  are  provided 
with  a  graduated  neck,  each  division  of  which  represents  one-tenth  per 
cent.,  by  weight,  of  butter  fat;  15  C.c.  of  milk  are  measured  into  the 
bottle,  3  C.c.  of  a  mixture  of  equal  parts  of  amyl  alcohol  and  strong 
hydrochloric  acid  added ;  the  bottle  is  then  filled  nearly  to  the  neck  with 


Pig.  55. — Babcock' s  bottle. 


Fig.  50.—  Babcock's  centrifuge. 


concentrated  sulphuric  acid  and  the  liquids  are  mixed  by  holding  the 
bottle  by  the  neck  and  giving  it  a  gyratory  motion.  The  neck  is  now 
filled  to  about  the  zero  point  with  a  mixture  of  sulphuric  acid  and  water. 
It  is  then  placed  in  the  centrifugal  machine  (Fig.  58).  After  rotation 
for  from  one  to  two  minutes  the  fat  will  collect  in  the  neck  of  the  bottle 
and  the  percentage  may  be  read  off,  allowance  being  made  for  the 
meniscus.  It  is  convenient  to  use  a  pair  of  dividers  in  making  the 
reading.  A  smaller  bottle  is  manufactured  for  this  test  and  should  it 
be  used  the  following  rule  for  the  proportions  of  reagents  may  be 
employed.  First,  determine  the  capacity  of  the  bottle  to  the  shoulder: 
fifty  per  cent,  of  this  for  the  milk,  ten  per  cent,  for  the  mixture  of  amyl 
alcohol  and  hydrochloric  acid,  and  forty  per  cent,  for  the  sulphuric  acid. 


RELATION    OF    FAT    TO    SPECIFIC    GRAVITY  103 


Of  these  methods  for  obtaining  the  percentage  of  fat,  that  of  Holt 
has  the  advantage  of  simplicity.  Its  drawbacks  are,  first,  the  length  of 
time — twenty-four  hours  being  necessary  for  making  the  test;  second, 
the  employment  of  the  arbitrary  algebraic  proportion ;  the  ratio  of  fat  to 
cream  (three  to  five)  being  questioned. 

The  Feser  lactoscope,  being  purely  an  optical  test,  is  open  to  the 
objection  of  all  color  tests,  that  different  eyes  give  different  estimates. 
Furthermore,  the  fact  that  the  same  weight  of  fat  retards  more  light 
when  in  the  form  of  small  globules  than  when  in  the  form  of  large 
globules,  renders  this  method  of  testing  unreliable. 

Marchand's  test  has  not  given  the  satisfactory  results  obtained  by 
other  methods. 

For  simplicity  of  detail  and  accuracy  in  results  the  Babcock  method 
is  rapidly  displacing  all  others.  A  cheap  machine,  from  which  most 
excellent  results  are  obtained,  carrying  as  low  as  two  bottles,  may  be 
sufficient.  Nor  is  the  water  jacket  of  the  larger  Babcock  machine 
essential  to  good  work,  since  by  the 
admixture  of  sulphuric  acid  with 
the  milk  sufficient  heat  is  evolved  to 
maintain  fluidity  of  the  fat  long 
enough  for  the  reading  of  one  or 
two  specimens.  Where  one  sample 
only  is  rotated,  the  opposite  arm  of 
the  centrifuge  should  be  balanced 
with  an  equal  wTeight  to  prevent 
accident. 


Fig.  57. — Leffman  and  Beam's  bottle. 


Fig.  58.— Centrifuge  for  Leffman  and  Beam's  bottle. 


The  Leffmann  and  Beam  process  is  here  detailed,  because  of  the  two 
advantages  it  possesses :  First,  the  bottles  are  adapted  by  their  form  and 
size  to  the  ordinary  office  centrifuge ;  second,  their  capacity  allows  of 
the  determination  of  fat  from  a  smaller  sample,  a  feature  of  practical 
importance  because  of  the  frequent  difficulty  in  securing  a  larger  quan- 
tity of  breast  milk. 

The  amount  of  fat  in  a  given  quantity  of  milk  may  be  determined 
to  within  one-tenth  of  one  per  cent,  by  the  above  methods. 

The  differing  effects  upon  the  specific  gravity  of  milk,  produced  by 
variations  in  its  different  constituents,  enables  us  to  form  some  estimate 
of  the  quantity  of  the  other  solids  when  the  specific  gravity  and  amount 
of  fat  are  known.  Thus  increasing  the  fat  diminishes  the  specific 
gravity,  while  it  is  augmented  by  increasing  other  solids.  Conversely, 
diminishing  the  fat  increases  the  specific  gravity,  while  diminishing  the 
other  solids  diminishes  it.    In  other  words,  the  higher  the  fat,  the  higher, 


104 


MILK   ANALYSIS 


of  necessity,  must  be  the  total  solids  to  maintain  an  average  specific 
gravity,  since  fats  have  a  tendency  to  lessen  it. 

Since  the  sugar  and  salts  maintain  a  fairly  constant  proportion  in 
milk,  the  determination  of  the  proteids  is  next  in  importance.  A  num- 
ber of  mathematical  formula?  have  been  employed  for  estimating  more 
definitely  than  the  above  the  percentage  of  total  solids  from  the  known 
fat  and  specific  gravity.  A  method  recommended  by  Eichmoncl,  which 
furnishes  uniform  results  within  the  limits  of  ordinary  variations,  is 
here  given.  The  total  solids  equal  the  sum  of  one-fourth  the  last  two 
figures  of  the  specific  gravity,  plus  six-fifths  of  the  percentage  of  fat, 
and  the  arbitrary  decimal  fourteen  one-hundredths,  the  algebraic  ex- 
pression of  the  equation  being  as  follows : 

Total  solids  =  fr+Ff  +.14 

In  this  method  it  is  assumed  that  the  sugar  maintains  a  constant  per- 
centage of  6.5  per  cent.,  and  the  salts  0.2  per  cent.  To  illustrate  the 
application  of  this  equation,  take,  for  example,  milk  with  a  specific 
gravity  of  1.028  and  fat  of  4  per  cent. : 

T.  S.=  2T8+f  of  4 +.14 
T.  S.=7+4.8  +.14 
T.  S.=11.94  per  cent. 


11.94  minus  10.70  (the  sum  of  the  fat,  4 ;   the  sugar,  6.5 ;    and  the 
salts  0.2)  equals  1.24  (the  remaining  proteids)  per  cent. 

Simpler  in  its  application  than  Richmond's  equation  is  the  following 
rule  given  by  Farrington  and  Woll,  which  furnishes  ap- 
proximately accurate  results : 

Divide  the  lactometer  reading  (Quevenne's  scale),  or 
the  last  two  figures  of  the  specific  gravity,  by  4  and  add 
to  this  one-fifth  of  the  percentage  of  the  fat;  result, 
solids  not  fat.  By  adding  to  this  the  weight  of  fat,  total 
solids  are  obtained. 


Example:   Fat  4  per  cent. 
(28-4)  +  (4-5)  = 


specific  gravity  1.028. 
7.8  solids  not  fat. 


Solids  not  fat  7.8  per  cent.  +  fat  4  per  cent.  =  Total 
solids  11.8  per  cent.,  a  result  differing  but  slightly  from 
that  obtained  by  Richmond's  rule. 

The  objection  that  the  above  methods  yield  approxi- 
mate, rather  than  positive,  quantitative  results,  may  be 
met  by  the  statement  that  uniformity  of  procedure  se- 
cures a  standard  of  comparison  of  great  clinical  value, 
even  though  the  determination  in  a  given  case  may  be 
lacking  in  chemic  accuracy.    The  microscope  is  of  value  in  ascertaining 


Fig. 


59.— Hydrome- 
ter. 


SPECIFIC    GRAVITY  105 

the  size  and  uniformity  of  the  fat  globules,  the  presence  of  colostrum 
corpuscles,  or  other  bodies  foreign  to  milk,  as  bacteria,  pus,  or  blood. 

The  specific  gravity  may  be  obtained  by  any  standard  hydrometer 
at  60°  F.  (15.5°  C.)  (Fig.  59).    The  specific  gravity  should  be  increased 

or  diminished  by  1  for  every  10°  F.  (5.0°  C.)  above  or  below  60°  F. 
(15.5°  C). 

Milk,  on  account  of  its  viscidity,  retains  minute  air-bubbles  after 
agitation,  a  fact  to  be  borne  in  mind  when  obtaining  specific  gravity. 

The  Babcock  milk-testing  outfit,  including  centrifuge,  bottles,  milk 
pipette,  acid  measure,  bottle  brushes,  lactometer,  and  thermometer  (or, 
better,  a  combination  lactothermometer)  may  be  obtained  from  any 
dairy  supply-house.  For  dairy  or  municipal  laboratory  work,  cen- 
trifuges are  made  for  holding  from  four  to  thirty-two  bottles,  but  for 
office-testing  a  two-  or  four-bottle  machine  is  better. 


CHAPTER   IX 
WEANING    AND    SUBSTITUTE    FEEDING 

SUPPLEMENTAL   FEEDING 

In  the  hygiene  of  infancy  the  question  of  substitute  feeding  is  of 
secondary  importance  only  to  that  of  lactation.  We  are  relieved  of  the 
responsibility  of  its  consideration  in  the  care  of  every  nursling  by  one 
circumstance  alone, — namely,  the  death  of  the  infant,  since  from  the 
first  establishment  of  lactation,  conditions  may  develop  at  any  time  which 
render  breast  feeding  impracticable.  The  character  of  the  lacteal  secre- 
tion is  subject  to  variations  as  a  result  of  some  well-known  influences 
and  of  many  that  are  still  unknown.  One  series  of  changes,  so  con- 
stant as  to  be  accepted  as  physiologic,  consists  in  a  steady  decrease  in 
the  proteids  and  salts.  The  total  solids  maintain  a  somewhat  uniform 
percentage  until  the  seventh  month,  on  account  of  the  constant  increase 
of  the  sugar.  After  this  time,  however,  the  decline  in  salts  and  proteids 
is  so  rapid  that  the  percentage  of  total  solids  is  steadily  reduced.  That 
the  nutrition  of  the  child  should  be  affected  visibly  by  the  decline  of 
these  important  constituents,  especially  at  a  time  when  material  is  de- 
manded for  rapid  growth,  is  not  a  matter  of  surprise.  This  would 
appear  to  furnish  good  reasons,  both  physiological  and  clinical,  for  the 
commencement  of  supplementary  feeding.  Moreover,  the  eruption  of 
the  teeth,  the  changes  in  the  salivary  secretion  as  well  as  those  of  the 
stomach  and  pancreas,  suggest  preparation  for  digestion  of  a  different 
class  of  foods. 

The  word  supplemental  is  used  here  not  to  indicate  a  total  change 
in  the  infant's  food,  but  merely  a  reinforcement,  particularly  in  those 
constituents  which  the  waning  function  of  the  mammary  gland  evidently 
fails  to  supply.  In  addition,  the  changes  in  the  digestive  secretions, 
especially  in  the  development  of  amylolytic  power,  afford  more  than  a 
hint  of  a  preparation  for  starch  digestion. 

The  changes  in  breast  milk,  above  referred  to  as  constantly  progres- 
sive, show  considerable  variation  as  to  the  time  of  their  occurrence  in 
different  women.  Thus,  one  mother  may  apparently  have  expended  her 
best  physiologic  energy  of  milk  elaboration  by  the  end  of  the  seventh 
month ;  while  on  the  other  hand,  another  may  not  show  the  same  degree 
of  deterioration  at  the  fifteenth  month.  To  the  queries,  When  shall  sup- 
plemental feeding  begin  ?  When  shall  substitute  feeding  be  inaugurated  ? 
or,  Shall  weaning  be  effected  gradually  or  abruptly? — it  must  be  evi- 
dent that  no  decisive  answer  can  be  given  that  will  apply  to  all  cases. 

One  indication  for  weaning  is  deficiency  in  normal  development, 
106 


INDICATIONS    FOR    WEANING  107 

which  is  frequently  best  shown  by  a  failure  to  gain  in  weight.  How- 
ever, weight  gain  is  not  always  evidence  of  normal  nutrition,  as  many 
rhachitic  babies  make  fat  rapidly. 

Due  reference  should  be  had  also  to  the  season,  as  it  is  well  known 
that  radical  food  changes  should  not  be  inaugurated  at  the  commence- 
ment of,  or  during  the  heated  term,  when  infants  are  especially  suscep- 
tible to  digestive  disorders.  Moreover,  the  eruption  of  an  unusually 
troublesome  tooth  might  well  delay  the  change  in  food.  Many  other 
circumstances,  which  need  not  be  enumerated,  should  be  taken  into  con- 
sideration, nor  must  it  be  understood  from  the  foregoing  that  a  radical 
change  in  the  infant's  diet  is  contemplated  by  the  term  "weaning."  In 
fact,  the  process  should  be  gradual,  the  infant  having  been  accustomed 
to  supplemental  feeding  as  often  as  once  a  day,  through  a  period  of 
several  weeks,  and  the  food  selected  should  conform  somewhat  closely 
to  the  milk  of  the  mother,  differing  at  first  in  the  lower  percentage  of 
proteids  and  fat,  as  determined  by  repeated  analyses  of  the  breast  milk. 

The  relation  of  an  infant  to  his  food  is  sometimes  arbitrary,  the  ex- 
planation of  which  is  ofttimes  difficult.  Thus  one  infant  fails  steadily 
at  the  breast  upon  which  another  thrives.  This  has  been  observed  even 
in  the  case  of  twins.  Transient  disagreement  should  not  be  considered 
sufficient  cause  for  rejecting  the  breast,  since  many  temporary  disturb- 
ances may  be  corrected  by  attention  to  hygiene.  Without  taking  time  for 
an  extended  presentation  of  the  advantages  of  breast  feeding  over  all 
other  methods,  it  should  be  stated  that  the  consensus  of  opinion  depre- 
cates early  weaning  unless  the  fact  be  established  that  the  mother's  milk 
cannot  be  made  to  agree.  In  this  connection  it  is  well  to  call  attention 
again  to  the  immense  advantages  to  be  derived  from  frequent  examina- 
tions of  the  mother's  milk,  also  to  the  principles  of  hygiene  discussed  in 
Chapter  VII. 

A  child  should  be  immediately  removed  from  the  breast  upon  the 
appearance  of  acute  infectious  disease  in  the  nurse.  So,  also,  in  a  well- 
grounded  suspicion  of  syphilis  or  tuberculosis  a  suitable  wet-nurse  should 
be  secured  in  case  the  infant  is  free  from  specific  infection. 

The  development  of  mastitis  renders  the  affected  breast  unfit  for 
nursing  while  suppuration  continues. 

The  growing  tendency  on  the  part  of  both  laity  and  physicians  to 
recommend  weaning  upon  the  slightest  pretext,  suggests  the  need  of 
more  emphasis  upon  the  injunction  not  to  adopt  substitution  for  breast 
feeding  until  it  is  clearly  demonstrated  that  the  latter  cannot  be  made 
to  agree.  It  should  not  be  forgotten,  in  considering  the  advisability  of 
substitution,  that  no  a  priori  reasoning  will  decide  what  food  will  agree 
in  every  case. 

In  the  majority  of  instances  change  in  food  is  largely  a  matter  of 
experiment.  On  the  other  hand,  it  must  be  remembered  that  many  in- 
fants are  deprived  of  their  right  to  a  fair  start  in  life  by  being  con- 
fined to  the  breast  which  fails  to  furnish  all  the  requisites  for  normal 
nutrition. 


108  WEANING   AND    SUBSTITUTE    FEEDING 

Reference  is  made  in  Chapter  VII  to  the  many  influences  that  dis- 
turb lactation,  transiently  or  permanently.  The  question  as  to  the  in- 
fluence of  menstruation  and  coitus  upon  lactation  is  of  paramount 
importance,  and  one  concerning  which  the  physician  is  often  consulted. 
Concerning  the  latter,  evidence  is  accumulating  to  show  that  excessive 
indulgence  very  frequently  deteriorates  the  quality  of  the  milk  of  the 
nursing  mother,  causing  an  increase  in  proteids,  with  the  appearance 
of  colostrum  corpuscles.  Under  these  circumstances  the  infant  com- 
monly gives  evidence  of  acute  gastro-intestinal  disturbance. 

Menstruation  frequently  disturbs  lactation.  Its  early  appearance 
may  not  require  weaning,  but  a  later  return  should  suggest  its  advisa- 
bility. 

The  occurrence  of  conception  is  an  indication  for  the  immediate 
removal  of  the  child  from  the  breast,  as  this  condition  renders  the  milk 
insufficient,  if  not  positively  injurious. 

When  it  becomes  evident,  from  any  of  the  conditions  enumerated,  that 
substitute  feeding  is  necessary,  the  question  what  shall  be  substituted 
is  of  the  greatest  importance.  Errors  in  the  management  of  substitute 
feeding  are  probably  responsible  to  a  greater  extent  than  any  other 
cause  for  the  high  infant  mortality. 

Without  entering  upon  an  extended  discussion  it  may  be  claimed  that 
the  best  substitute  is  the  wet-nurse.  The  drawbacks  to  wet-nursing  are 
many  and  extremely  trying.  It  is  probably  on  account  of  these  that  this 
substitution  is  not  more  frequently  resorted  to  in  this  country.  The 
difficulties  attending  the  securing  and  selection  of  a  suitable  wet-nurse 
undoubtedly  lead  many  physicians  and  parents  to  shut  their  eyes  to  its 
importance,  and  to  accept  the  dictum  of  some  eminent  teachers  that  arti- 
ficial feeding  can  be  conducted  successfully  in  ninety  per  cent,  of  the 
cases.  They  forget  that  the  tacit  admission  that  the  remaining  ten  per 
cent,  may  survive  only  upon  the  breast,  is  the  strongest  argument  in 
favor  of  giving  to  all  infants  the  implied  advantage  of  this  best  method 
of  feeding.  Who  is  willing  to  admit  that  he  deliberately  rejects  the  best 
simply  because  something  inferior  may,  with  care,  be  made  to  do?  It 
is  to  be  hoped  that  with  the  growing  appreciation  of  the  importance  of 
breast  milk  for  young  infants,  systematized  organizations  for  the  supply 
of  properly  certified  wet-nurses  will  soon  supersede  the  haphazard 
method  of  selection  now  in  vogue. 

The  wet-nurse  should  be  chosen  with  definite  reference  to  her  tem- 
perament, the  quantity  and  quality  of  her  milk,  and  her  freedom  from 
syphilis  or  tuberculosis.  Her  milk  should  be  examined  both  analytically 
and  microscopically.  The  breasts  and  nipples  should  give  evidence  of 
abundant  and  free  lactation.  A  firm  small  gland  is  preferable  to  the 
large  fat  variety.  A  point  to  be  observed  is  that  after  nursing  there 
should  be  a  marked  decrease  in  the  size  of  the  gland,  which  should  refill 
within  three  hours.  The  nipple  must  be  of  good  proportions  and  free 
from  fissures  and  excoriations.  On  the  Avhole,  the  best  test  for  a  nurse 
is  the  condition  of  her  own  child,  who  should  always  be  carefully  ex- 


WET-NURSES  109 

amined  as  to  his  nutrition  and  freedom  from  syphilitic  stigmata.  On 
this  account  a  nurse  whose  child  is  at  least  three  months  old  is  usually 
to  be  preferred.  Nor  is  it  essential  that  the  ages  of  the  infants  should 
exactly  correspond,  providing  lactation  has  become  well  established. 
Other  things  being  equal,  there  are  some  reasons  why  a  multipara  should 
be  selected. 

It  should  be  remembered  that  the  function  of  lactation  is  at  its  best 
between  the  ages  of  twenty-one  and  thirty-five  years.  A  nurse  who  has 
lost  her  child  is  more  likely  to  give  her  undivided  attention  than  one 
whose  child  has  been  displaced.  Should  the  first  wet-nurse's  milk  fail 
to  agree  it  need  be  no  cause  for  discouragement,  as  sometimes  success  is 
attained  only  after  repeated  trials. 

In  case  a  wet-nurse  is  not  available,  it  will  become  necessary  to  adopt 
artificial  feeding.  More  has  been  written  and  said  concerning  this  sub- 
ject during  the  past  fifteen  years  than  all  other  pediatric  subjects  com- 
bined. 


CHAPTER    X 
ARTIFICIAL    FEEDING 

FOOD   ESSENTIALS 

Artificial  feeding  of  infants  is  a  subject  concerning  which  consid- 
erable partisanship  has  developed,  and  teachers  have  been  designated  as 
belonging  to  this  or  that  class  of  ' '  feeders. ' : 

A  few  essentials  from  Cheadle,  although  written  sixteen  years  ago, 
may  be  of  value  in  assisting  the  student  to  a  practical  application  of 
some  of  the  principles  already  outlined  in  the  preceding  chapters. 

(1)  The  food  must  contain  the  different  elements  in  about  the  same 
proportions  as  found  in  human  milk. — viz.,  proteids,  one  to  two  per 
cent. :  fats,  three  to  four  per  cent. ;  carbohydrates,  six  to  seven  per  cent. ; 
salts,  two-tenths  per  cent. ;  water,  eighty-eight  per  cent.  This  represents 
theoretically  the  ideal  for  a  balanced  nutrition.  The  chemist  can  readily 
produce  a  mixture  which  duplicates  breast  milk  in  the  nutritive  value  of 
its  constituents  and  even  resembles  somewhat  closely  that  emulsion  in 
its  physical  appearance,  but  the  dismal  array  of  failures  to  reproduce 
mothers'  milk  by  a  synthetic  arrangement  of  apparently  similar  con- 
stituents obtained  from  other  sources,  is  an  emphatic  reminder  of  the 
limitations  of  both  chemical  and  physiological  knowledge. 

(2)  It  should  not  be  purely  vegetable,  but  must  contain  a  large  pro- 
portion of  animal  matter.  Most  vegetable  substances  are  deficient  in 
available  proteids  and  yield  but  a  small  quantity  of  fat.  Moreover,  it  is 
known  that  the  infant  does  not  assimilate  them  as  easily  and  fully  as 
those  derived  from  animal  sources,  even  though  these  ingredients  be 
supplied  in  the  proper  percentages. 

(3)  It  must  be  in  a  form  suited  to  infantile  digestion.  The  digestive 
organs  have  only  recently  assumed  their  function,  and  are  designed  to 
deal  solely  with  the  bland,  dilute,  and  easily  dissolved  nutriment  of 
mother's  milk.  In  the  natural  method  of  feeding  the  infant  gets  his 
nourishment  in  the  same  form  at  every  meal :  so  in  artificial  feeding 
variety  is  not  desirable.  It  is  presumed  that  infants  under  six  months 
are  unable  to  digest  much  starch  from  the  paucity  of  ptyalin  and  amylop- 
sin :  hence,  for  this  age  any  great  amount  of  starch  in  a  food  is  enough 
to  condemn  it.  As  the  walls  of  the  stomach  are  lacking  in  muscular 
power  and  the  secretions  are  feeble,  it  is  evident  that  this  organ  is  unable 
to  deal  with  large  masses  of  solid  matter.  Solids  can  be  digested  only 
in  a  state  of  minute  subdivision. 

(4)  The  total  quantity  in  twenty-four  hours  must  represent  the 
equivalent,  in  nutritive  value,  of  from  one  to  three  pints  of  human  milk, 

110 


DEVELOPMENT   OF  DIGESTIVE   TRACT  BY  FOOD      111 

according  to  the  infant's  age.  No  fixed  rule  can  be  given  for  all  children. 
Careful  observation  of  the  infant  as  to  whether  he  rejects  some  of  his 
food  soon  after  ingestion,  or  seems  hungry  half  an  hour  after  feeding, 
may  prove  a  guide.  The  best  indication  that  he  is  receiving  his  full 
equivalent  is  a  steady  weekly  gain  of  from  two  to  five  ounces, — or  more 
in  the  early  months. 

(5)  It  must  2>ossess  the  antiscorbutic  property.  It  is  not  yet  known 
in  what  this  consists.  It  is  known  that  infants  at  the  breast  very  rarely 
suffer  from  scurvy,  and  that  the  disease  is  found  among  those  fed  upon 
condensed  or  sterilized  milk,  or  upon  desiccated  preparations.  Prompt 
recovery,  with  food  unchanged  (except  the  discontinuance  of  steriliza- 
tion), has  been  reported  by  several  observers.  Fresh  milk,  therefore, 
possesses,  in  addition  to  the  important  principles,  this  antiscorbutic  ele- 
ment, but  not  in  large  proportion,  for  milk  in  extreme  dilution  will  not 
prevent  the  development  of  this  disease. 

(6)  It  must  be  fresh,  clean,  and  free  from  excessive  bacterial  content. 
Hydrochloric  acid  has  antiseptic  properties,  it  is  true,  but  the  stomach 
secretes  only  a  limited  quantity  of  it  during  the  first  half  year.  Hence, 
infants  are  extremely  susceptible  to  gastro-enteric  disorders,  having  lit- 
tle resistance  to  bacterial  invasion.  The  deadly  toxins  which  develop  in 
old  milk  may  resist  all  efforts  at  sterilization. 

(7)  Another  essential,  voiced  by  Chapin,  may  well  be  added, — viz., 
in  feeding  young  animals  it  is  not  only  necessary  to  supply  the  proper 
quantities  of  nutritional  elements,  but  they  must  be  in  such  form  as  nor- 
mally to  develop  the  digestive  tract. 

This  writer  calls  attention  to  the  physical  and  chemical  differences 
in  the  milk  of  various  mammals,  and  shows  that  each  is  especially 
adapted  not  only  to  the  nutrition  but  to  the  digestive  development  of 
its  particular  young, — as,  for  instance,  the  bovine  calf,  which,  doubling 
birth  weight  in  forty-seven  days,  attains  pubescence  in  one  year  with 
a  ruminant  digestive  tract  twenty  times  the  body  length  that  must  be 
fitted  quickly  to  obtain  food  elements  from  coarse  herbage.  He  needs 
a  dense,  quickly  curding,  rich  proteid  milk  for  early  development  of 
both  muscular  and  secretory  functions  in  his  stomach,  which  constitutes 
seventy  per  cent,  of  the  digestive  tract.  While  the  human  infant,  who 
doubles  weight  in  one  hundred  and  sixty  days  and  attains  puberty  in 
fourteen  years,  finds  only  in  his  mother's  milk  the  ingredients  suitable 
for  the  development  of  his  digestive  tract,  which  is  only  six  times  his 
body  length,  and  of  which  only  twenty  per  cent,  is  stomach.  Hence  the 
early  feeble  gastric  digestion  must  be  slowly  cultivated  by  gradually 
increasing  density  of  the  flocculent  curds  characteristic  of  human  milk 
alone. 

It  has  been  stated  that  the  substitute  feeding  of  infants  is  a  broad 
subject.  If  the  breadth  of  this  subject  be  indicated  by  the  number  and 
apparent  variety  of  infant  foods  on  the  market,  a  student  may  well 
quail  before  it.  To  the  query  why  such  a  large  number  of  foods  and 
preparations,  the  reply  has  been  made  that  commercial  enterprise  is 


112  ARTIFICIAL    FEEDING 

responsible  for  this,  as  it  is  also  for  the  innumerable  foods  and  prepara- 
tions for  adult  use ;  also  that  manufacturing  ingenuity  is  stimulated  to 
furnish  presumed  nutriment  in  a  great  variety  of  forms  by  the  whims, 
caprices,  and  tastes  of  individual  appetites. 

Man  is  an  animal  with  educated  or  perverted  tastes  which  result  in 
a  demand  for  variety  in  his  viands.  He  is  capable,  also,  of  determining, 
to  some  extent,  the  nutriment  derived  therefrom.  At  any  rate,  he  may 
recognize  some  of  the  more  immediate  effects  from  the  ingestion  of  dif- 
ferent foods.  The  infant,  on  the  other  hand,  is  but  slightly  conscious  of 
food  effects,  either  immediate  or  remote.  Rarely  in  early  life  has  he 
tastes,  either  acquired  or  perverted.  Instinctively  he  craves  nourishment, 
and  is  almost  invariably  satisfied  with  that  furnished  normally  by  the 
breast.  Variety  in  form  or  flavor  is  neither  desired  nor  desirable.  Ref- 
erence to  the  essentials  above  enumerated  will  show  that  uniformity  of 
food,  containing  the  five  constituents,  is  what  the  infant  requires  and 
with  which  he  is  satisfied.  The  great  variety  of  baby  foods  in  the  market 
is  partly  the  result  of  prejudice  and  ignorance. 

The  average  mother's  withdrawing  her  breast  from  the  infant  is 
likened  to  a  vessel  at  anchor  in  a  safe  roadstead,  slipping  the  cable  in 
the  absence  of  pilot,  chart,  or  compass.  The  baby  knows  not  what  he 
needs,  the  mother  knows  little  more ;  but  she  can  read,  and  the  claims 
of  the  enterprising  food  agents  attract  her  attention.  Too  often  physi- 
cians, also,  derive  their  supposed  knowledge  of  infant  dietetics  from  the 
same  source. 

The  spectacle  is  by  no  means  uncommon  of  anxious  parents  running 
the  entire  gamut  of  the  advertised  preparations  in  the  market  in  the 
hope  of  stumbling  upon  something  which  will  agree  with  the  baby.  Nor 
is  this  practice  confined  exclusively  to  the  laity.  On  account  of  its 
cheapness  and  abundant  supply,  it  is  not  strange  that,  in  his  quest  for 
a  substitute  food,  man  should  turn  to  the  milk  of  the  lower  animals, 
possessing  as  it  does  the  grosser  physical  characteristics  of  mother's 
milk,  with  the  confirmation  of  its  apparent  identity  by  the  earlier 
chemic  analyses.  So  in  different  portions  of  the  globe  mammals,  in- 
cluding the  cow,  goat,  sheep,  ass,  mare,  and  camel,  have  contributed  their 
lacteal  product  for  the  orphaned  human  infant.  For  obvious  reasons 
the  cow  furnishes  the  most  available  product  in  civilized  countries,  where, 
unfortunately,  substitute  feeding  is  in  greatest  demand.  But  little  ques- 
tion was  raised  in  former  years  as  to  its  value  and  availability  as  a  sub- 
stitute. Now  and  then,  to  be  sure,  in  the  discussion  of  infantile  disorders, 
some  astute  observer  might  refer  parenthetically  to  the  fact  that  in 
critical  conditions  infants  at  the  breast  afforded  more  favorable  prog- 
noses than  the  bottle-fed.  It  was  not  until  the  attention  of  the  world 
was  arrested  by  the  startling  mortality  in  the  latter  class  that  the  differ- 
ences between  the  milks  of  different  mammals  in  their  relation  to  the 
requirements  of  the  infant,  began  to  be  studied  systematically. 

The  result  is  seen  in  the  immense  impetus  given  to  the  study  of  the 
food  question,  to  the  extent  that  the  deductions  of  yesterday  are  refuted 


COMPARISON    OF    BOVINE    AND    HUMAN    MILK        113 

by  those  of  to-day,  and  the  accepted  conclusions  of  last  year's  text-book 
may  be  obsolete  ere  a  second  edition  leaves  the  press.  In  this  critical 
research  and  rapid  advance  of  knowledge,  the  whole  world  has  furnished 
contributions  from  the  best  minds,  but  from  no  section  has  there  been 
drawn  more  valuable  practical  application  than  during  the  past  fifteen 
years  by  a  brilliant  coterie  of  Americans.  Leeds,  Chittenden,  Babcock, 
Harrington,  Leffman  and  Beam,  Jacobi,  Rotch,  Holt,  Starr,  Meigs, 
Chapin,  Van  Slyke,  Russell,  Hart,  Richmond,  and  the  Adriances,  have 
placed  infant  feeding  in  America  on  a  plane  in  advance  of  other 
countries. 

As  a  result  of  this  work,  some  of  the  reasons  why  cow's  milk  does  not 
meet  all  the  requirements  of  the  infant  have  been  demonstrated.  The 
results  of  recent  analyses  give  the  gross  constituents  of  cow's  milk  and 
mother's  milk  as  follows: 

Cow's  milk,  Mother's  milk, 

per  cent.  per  cent. 

Specific  gravity    1.032  1.030 

Total  solids   14-13  13-12 

Proteids    3-4  1-2 

Fat    3-4  3-4 

Sugar    4.50  0-7 

Salts    0.7  0.1-0.2 

Reaction    Acid  Faintly  acid.* 

Bacteria    Swarming  with  f  None  or  few. 

It  will  be  seen  that  they  differ  but  little  in  specific  gravity,  in  the 
quantity  of  their  total  solids  and  water,  and  in  their  percentage  of  fat ; 
more  widely  in  their  salts,  sugar,  and  chemic  reaction,  and  most  widely 
in  regard  to  their  proteids  and  bacterial  content. 

So  far  as  positively  known,  the  fats  and  lactose  in  cow's  milk  have 
the  same  food  value  as  similar  constituents  in  breast  milk.  This  state- 
ment, which  is  now  questioned,  may  be  disproven  by  a  better  knowledge 
of  the  chemistry  of  milk  and  the  physiology  of  infant  digestion.  Many 
disturbances  of  digestion  and  nutrition  are  traceable  directly  to  the 
proteids  and  fats. 


*  To  phenolphthalein  test. 

t  This  refers  to  cow's  milk  as  it  reaches  the  consumer. 


CHAPTER    XI 
ARTIFICIAL    FEEDING— Continued 


PERCENTAGE    FEEDING 

The  excess  of  proteids  in  cow's  milk  has  been  considered  the  principal 
cause  of  its  indigestibility.  As  a  result  of  this  belief,  reduction  of  this 
constituent  has  been  practised  by  the  addition  of  water;  so  that  rules 
for  dilution  of  cow's  milk  in  proportion  to  age  of  infant  are  found  in 
older  text-books.  Results,  however,  showed  that  in  these  dilutions  the 
nutrition  suffered  from  a  coincident  diminution  of  fats  and  sugars. 
Consequently,  it  was  recommended  that  the  percentage  of  lactose  and 
fats  be  maintained  by  the  addition  of  sugar  of  milk,  and  cream,  while 
the  reduction  of  proteids  was  effected  by  the  proper  addition  of  water. 
This  process  of  modification  came  to  be  known  as  the  "Rotch  method" 
from  the  energy  displayed  by  that  eminent  teacher  in  perfecting  its 
details.  Laboratories  for  this  modification  have  been  established  in  the 
leading  American  cities,  to  which  orders  are  sent  for  definite  percentages 
of  modified  milk,  as  drugs  are  ordered  by  prescription  from  a  pharmacy. 
Too  much  praise  cannot  be  accorded  the  distinguished  originator  of  the 
milk  laboratory,  since,  more  than  any  other  agent,  it  has  been  the  means 
of  leading  the  profession  to  the  habit  of  definite  percentage  feeding.  It 
will  be  seen  from  the  accompanying  order  blank  that  the  physician  may, 
at  will,  control  the  amount  of  different  ingredients,  varying  their  per- 
centages to  meet  the  apparent  requirements  of  the  little  patient.     For 

R 


Per  Cent. 

Remarks 

Fat 

Heat  at                                                  °  F 

Milk-Sugar 

Albumoids 

Mineral  Matter 

Total  Solids 

Infant's  Age 

100  00 

1 

Order 
Date . . 


.190 


Signature 


114 


FAILURE    IX    PERCENTAGE    FEEDING  115 

some  of  the  indications  for  these  variations,  the  reader  is  referred  to 
Chapter  XII. 

Percentage  feeding,  or  the  American  method  as  it  is  designated 
abroad,  while  founded  upon  a  misconception  of  the  identity  of  the  con- 
stituents of  cow's  milk  and  mother's  milk,  is  still,  now  that  these  differ- 
ences are  better  understood,  by  far  the  best  method  of  feeding  with  the 
best  of  all  substitutes. 

Its  adaptability  to  delicate  changes  in  the  proportions  of  constituents 
and,  best  of  all,  the  habit  of  thinking  in  percentages  and  the  consequent 
appreciation  of  the  importance  of  slight  variation  in  the  food,  not  to 
mention  the  great  advantage  of  a  daily  record  of  the  diet,  are  but  a  few 
of  the  advantages  over  the  haphazard  rule-o  '-thumb  practice  formerly 
in  vogue. 

Many  of  the  failures  in  percentage  feeding  result  from  a  mistaken 
notion  that  the  modified  milk  must  correspond  in  constituent  percentages 
with  human  milk,  forgetting  the  irreconcilable  differences  in  their  chemi- 
cal characters  and  the  coagulability  of  the  proteids,  and  the  differences 
in  digestive  function  of  calf  and  child.  At  the  beginning  the  percentage 
of  ingredients,  with  the  possible  exception  of  lactose,  should  be  low. 
After  toleration  is  established  they  may  be  cautiously  increased.  Thus, 
a  child  normally  nourished  on  breast  milk  yielding  proteids  1.50  per 
cent. ;  fat  3.50  per  cent. ;  lactose  6.50  per  cent.,  if  transferred  to  modi- 
fied cow's  milk  might  begin  with  proteids  0.50  per  cent. ;  fat  2  per  cent., 
and  milk  sugar  6  per  cent.  The  amount  for  each  feeding  may  well 
be  too  little  rather  than  too  much.  A  fair  rule  to  follow  in  the  majority 
of  cases  is  that  the  proteids  should  rarely  exceed  one-third  of  the  fats. 
Alkalinity  is  desirable  not  because  mother's  milk  is  alkaline,  for  it  is 
not,  but  because  it  retards  the  precipitation  of  cow  casein  in  its  char- 
acteristic dense  curds  with  which  the  infant  digestive  tract  is  unable 
to  cope.  For  this  reason  the  amount  of  lime-water  or  sodium  bicarbonate 
ordered  should  be  proportionate  to  the  amount  of  proteids  prescribed. 
The  routine  practice  of  ordering  alkalinity  five  per  cent.,  which  means 
one  ounce  of  lime-water  in  a  twenty-ounce  mixture  regardless  of  the  milk 
content,  which  may  vary  from  one  to  sixteen  or  more  ounces,  is  neither 
rational  nor  scientific  if  its  purpose  be  as  above  stated.  As  a  rule,  alka- 
linity should  be  increased  with  increase  of  proteids. 

Xo  one  can  prescribe  intelligently  for  an  unknown  patient.  The 
infant's  personal  equation  is  always  to  be  considered.  Hence,  arbitrary 
formula1  in  text-books  are  apt  to  be  misleading  and  pernicious.  A 
modicum  of  brains  is  an  essential  ingredient  in  every  bottle  of  food. 

If  the  paucity  of  soluble  albumin  and  the  excess  of  the  refractory 
casein  in  cow's  milk  (page  113)  cause  digestive  intolerance  soluble  or 
whey  proteid  may  be  designated  in  the  prescription  up  to  0.9  per  cent.. 
above  which  any  increase  must  include  some  casein.  The  milk  labora- 
tory is  in  reality  a  food  pharmacy  from  which  any  rational  food  mix- 
ture may  be  ordered.  The  physician  may  specify  e^s:  albumin,  meat  pro- 
teids, cereal  gruels,  jellies,  cane-sugar,  whey,  or  buttermilk  in  the  mix- 


116 


ARTIFICIAL    FEEDING 


ture  as  his  judgment  dictates.  So,  too,  sterilization,  pasteurization, 
gravity  cream  or  centrifugalized  cream  are  subject  to  the  physician's 
order. 

The  expense  incident  to  the  laboratory  manipulation,  and  the  im- 
practicability of  its  establishment  except  in  large  cities,  will  necessarily 
limit  the  field  of  operation  for  this  very  valuable  adjunct.  Consequently 
home  modification  is  of  greater  interest  to  the  majority  of  practitioners. 
In  this  connection,  the  protection  of  the  supply  will  ever  continue  to  be 
the  most  important  consideration  in  substitute  feeding  with  cow's  milk. 

That  many  disorders  of  infancy  are  due  to  the  presence  of  bacteria 
in  cow's  milk  has  long  been  known.  Passing  over  the  infections  from 
the  presence  of  such  micro-organisms  as  those  of  tuberculosis,  typhoid 
fever,  scarlet  fever,  diphtheria,  etc.,  for  the  time  being,  it  may  be  stated 
that  the  proneness  of  cow's  milk  to  decomposition,  with  its  effect  upon 
the  nursling,  was  early  recognized  as  constituting  one  of  the  commonest 
dangers  of  milk  feeding.    Hence  the  hygienic  dairy  management  became 


Fig.  60. — Freeman's  pasteurizer. 

a  question  of  the  highest  importance.  It  has  been  demonstrated  that 
milk  production  may  be  so  guarded  as  to  furnish  a  product  compara- 
tively free  from  pathogenic  micro-organisms.  The  same  care  in  the 
selection  of  the  cow  that  was  recommended  in  the  selection  of  the  wet- 
nurse,  the  same  aseptic  details  in  her  care  and  in  the  handling  of  the 
milk  that  were  required  in  the  chapters  on  infant  hygiene,  will  insure 
food  that  is  practically  sterile. 

All  large  cities  now  have  milk  commissions  either  in  connection  with 
or  independent  of  the  health  departments.  As  a  result  of  recent  activity 
in  this  direction,  city  milk  supply  has  improved  to  a  marked  degree. 
A  long  step  forward  is  the  delivery  on  ice  of  milk  cooled  and  bottled  in 
the  country.  The  Chicago  Milk  Commission,  acting  independently  yet 
in  unison  with  the  municipal  health  authorities,  has  during  the  past 
three  years  furnished  thousands  of  children  with  milk,  both  whole  and 
modified,  at  a  price  slightly  below  cost. 

The  question  of  grocery  milk  seems  practically  hopeless  so  far  as 
reformation  goes.     Only  by  years  of  patient  education  may  the  public 


MILK    SUPPLY 


117 


be  brought  to  appreciate  the  dangers  that  lurk  in  the  open  can  of  cheap 
milk.  It  rests  with  the  doctor,  who  should  inform  himself  thoroughly 
upon  every  phase  of  the  subject.  Circulars  giving  full  information  may 
be  obtained  from  health  departments  or  milk  commissions  in  any  city, 
or  from  the  United  States  Bureau  of  Animal  Industry. 

In  case  the  milk  supply  or  its  handling  is  not  above  suspicion,  steril- 
ity may  be  secured  by  the  application  of  heat.  Different  sterilizing 
devices  are  in  use,  from  the  mere  scalding  of  the  milk  in  a  farina  kettle 
to  the  more  elaborate  apparatus  of  Soxhlet,  Arnold,  Freeman,  or  Boeck- 
man  (Figs.  60,  61).  A  temperature  of  212°  F.  (100°  C),  maintained  for 
over  an  hour,  is  required  for  complete  sterilization.  Milk  thus  treated 
and  protected  from  subsequent  infection  will  resist  decomposition 
changes  for  two  or  three  days,  at  ordinary  temperature.  For  prolonged 
keeping,  three  sterilizations,  after  intervals  of  twenty-four  hours,  are 


Fig.  61.— Arnold's  sterilizer. 


necessary.  For  immediate  use,  however,  pasteurization — exposure  to  a 
temperature  of  155°  F.  (68°  C.)  for  forty  minutes — is  sufficient  to  meet 
all  the  requirements.  Objections  to  prolonged  boiling  are  due  to  changes 
in  the  nutritive  quality  of  milk  thus  treated;  the  coagulation  of  the 
lactalbumin  causing  a  loss  in  food  value,  at  the  same  time  the  casein  is 
rendered  less  soluble,  as  well  as  some  of  the  calcium  salts.  Besides  these 
changes  the  natural  ferments  are  destroyed  as  well  as  the  antiscorbutic 
element.  If  the  milk,  originally  clean,  is  cooled  to  40°  F.  (4.5°  C.)  im- 
mediately after  milking  and  kept  on  ice  during  shipment,  it  is  better 
used  raw  in  the  majority  of  cases. 

The  dense  coagulability  of  the  casein  of  cow's  milk  renders  the  addi- 
tion of  an  alkali  necessary.  For  this  purpose  bicarbonate  of  sodium  or 
liquor  calcis  may  be  used  (preferably  the  latter,  of  which  five  to  forty 
per  cent,  may  be  necessary).  Of  the  sodium  bicarbonate,  one  to  two 
grains  to  the  ounce  of  milk  in  the  mixture  may  be  sufficient. 


CHAPTER    XII 
ARTIFICIAL    FEEDING— Continued 

HOME    MODIFICATION    OF    MILK 

Of  rules  and  methods  for  home  modification  a  great  number  and 
variety  have  appeared,  with  the  promise  of  more  to  come.  Some  are  so 
crude  as  to  amount  to  little  more  than  dilutions,  while  others  are  so 
intricate  in  their  formuke  and  equation  reductions  as  to  be  of  little 
value  except  as  mathematical  curiosities.  A  rule  from  Baner,  which 
commends  itself  on  account  of  its  simplicity  and  efficiency,  is  here  given. 
Its  application  presupposes  the  percentages  of  fat,  proteids,  and  sugar 
in  cow's  milk  to  be  four  each.* 

First  determine  the  quantity  needed  for  the  day's  feeding  and  the 
percentages  of  ingredients.  To  find  the  amount  of  cream  that  will  have 
to  be  used  in  the  mixture,  subtract  proteid  per  cent,  from  fat  per  cent, 
and  multiply  the  remainder  by  the  total  number  of  ounces  of  mixture 
divided  by  twelve.  This  gives  the  cream  (16  per  cent.)  in  ounces, — e.g., 
(Fat— Proteid)  X  Qna1118tlty  =  Cream. 

For  estimation  of  milk,  multiply  quantity  of  mixture  by  proteids 
per  cent,  and  divide  by  four.     This  gives  total  mixture  of  milk  and 
cream.    Subtract  from  this  the  amount  of  cream,  the  remainder  will  rep- 
resent the  milk, — e.g.,  Q"ant>ty|  proteids  _  mjxture  of  cream  and  milk. 
Mixture- — cream  =  milk. 

To  obtain  the  amount  of  milk  sugar,  multiply  the  difference  between 
sugar  per  cent,  and  proteid  per.  cent.,  by  quantity  of  mixture  and  divide 
by  100,— e.g.,  w»«"— P"*")* Quantity  _  ammmt  of  milk  sugar  (in  ounces). 

For  twenty  per  cent,  cream  the  denominator  of  the  cream  formula 
should  be  16  instead  of  12,  and  for  twelve  per  cent,  cream  8  would  be 
required  for  the  denominator.  After  the  quantities  of  cream  and  milk 
have  been  determined,  the  rest  of  the  total  quantity  of  mixture  is  made 
up  by  the  addition  of  water  or  other  diluent.  (Note. — The  use  of  the 
centrifugal  separator  in  our  best  dairies  brings  definite  percentage  cream 
within  the  reach  of  the  majority  of  city  consumers.  Gravity  cream  from 
four  per  cent,  milk  may  be  obtained  in  approximately  definite  per- 
centages as  follows :  Set  the  milk  in  a  deep  vessel  on  ice  for  twelve  hours ; 
the  upper  fifth  will  represent  sixteen  per  cent,  cream,  best  secured  by 
siphoning  from  the  bottom  the  lower  four-fifths.  Ordinary  gravity 
cream  represents  sixteen  per  cent,  fat ;  from  this  twelve  per  cent,  cream 
may  be  obtained  by  taking  two  parts  sixteen  per  cent,  cream  and  one 
part  milk  of  four  per  cent,  fat.) 

*  The  variability  of   different   milks   in   their   constituent   percentages   renders 
occasional  testing  necessary   (page  100)   for  accuracy  in  feeding  modifications. 
118 


MODIFICATION    OF    MILK 


119 


Ounces  of  Fat-free 

Milk 

, 

percentage  of 

Ounces  of  Crea 

in. 

use 

d  with  Creams  of 

Ounces  of 

s  g  «j 

„• 

^j 

^ 

ti 

<j 

j 

„• 

j 

§  g 

T3 

a 

©  s 

aS 

t^a 

a 

-.  ? 

ag 

>.? 

C 

~  'r 

—  >  9Q 

6 

a 

& 

s 

O 
b 

a  ■■z 
a.- 

a  v 

f  p. 

J:  u 

.2  p. 

g  z 

*  s. 

S   P. 

"3  £ 

5  Pi 

.2  p. 

§£ 

gg 

—  = 

i  i 

5  a 

6S& 

=  3^ 

ft 

l~ 

00 

fi 

< 

H 

H 

CO 

H 

H 

H 

•/. 

H 

2 

n 

H 

co 

1 

1.50 

4.50 

0.25 

5 

* 

* 

* 

1% 

* 

* 

* 

0 

1 

17% 

2 

0.33 

2 

1.50 

4.50 

0.50 

5 

3 

2% 

2 

1$ 

0 

x 

1 

1% 

1 

16 

2 

0.61 

3 

2.00 

5.00 

0.25 

5 

* 

* 

* 

2 

* 

* 

* 

0 

1 

17 

2% 
2% 

0.75 

4 

2.00 

5.00 

0.50 

5 

* 

3% 
8H 

2% 
2V~ 

2 

* 

0 

3»4 

1 

1 

15% 

11', 

!■■', 

\m 

14% 
13J2 

0.73 

5 

2.00 

5.00 

0.75 

5 

4 

2 

A 

iv 

2% 

1 

2 

1.01 

6 

2.00 

5.50 

1.00 

5 

4 

2U 

2 

2^ 

3% 

1 

2H 

2% 

2H 

2% 
2% 
2% 

2H 
2% 
2% 

1.30 

7 

2.50 

5.00 

0.50 

5 

* 

* 

3% 

3H 
3£f 

Wa. 

2% 
2V* 

* 

* 

0 

1 

0.73 

8 

2.50 

5.50 

0.75 

5 

* 

4% 
4% 

* 

4 

1% 

2 

1 

1.01 

9 

2.50 

6.00 

1.00 

5 

5 

2$ 

1 

s« 

1 

1.23 

10 

3.00 

6.00 

0.50 

5 

* 

* 

3 

* 

* 

0 

1 

15i4 

0.84 

11 

3.00 

6.00 

0.75 

5 

* 

5 

3 

* 

0 

1% 
2$ 

2 

1 

14 

1.12 

12 

3.00 

6.00 

1.00 

5 

6 

5 

3 

0 

1 

3 

1 

13 

1.35 

13 

3.00 

6.00 

1.25 

5 

0 

5 

3 

1% 
2% 
5% 

2% 
3$2 

3% 

4% 
5i2 

1 

11% 

10% 
7% 
15% 
14% 
13% 

1.35 

14 

3.00 

6.50 

1.50 

5 

6 

5 

W 

3 

4%2 

1 

1.91 

15 

3.00 

6.50 

2.00 

5 

6 

5 

3% 

3 

6$ 

7% 

8% 

1 

2 

2.68 

16 

3.50 

6.00 

0.50 

5 

* 

* 

* 

3% 
3% 

3% 
3% 
3% 

* 

* 

* 

0 

1 

2% 
2ii 

0.78 

17 

3.50 

6.00 

0.75 

5 

* 

* 

4$ 

* 

* 

0 

1 

1 

1.01 

18 

3.50 

6.50 

1.00 

5 

* 

5% 

* 

0 

1% 

2% 

1 

2*2 

1.26 

19 

3.50 

6.50 

1.25 

5 

7 

w* 

4$ 

% 

1% 

3 

4 

1 

11 % 

2% 

1.68 

20 

3.50 

6.50 

1.50 

5 

7 

5% 

4$ 

2 

3H 

4% 

5'% 

1 

10 

2% 

2$. 

2.02 

21 

4.00 

6.00 

0.60 

5 

* 

* 

* 

4 

* 

* 

* 

0 

1 

15 

0.78 

22 

4.00 

6.00 

0.75 

5 

* 

* 

5 

4 

* 

* 

0 

1 

1 

14 

1.12 

23 

4.00 

7.00 

1.00 

5 

* 

* 

5 

4 

* 

* 

1 

2 

1 

13 

1.35 

24 

4.00 

7.00 

1.25 

5 

* 

6% 

5 

4 

* 

2g 
4% 
7% 

10% 

2% 

3% 

1 

11% 

1.68 

25 

4.00 

7.00 

1.50 

5 

8 

6% 

5 

4 

1 

4 

5 

1 

10 

2% 
2% 

2.02 

26 

4.00 

7.00 

2.00 

5 

8 

6% 
Wa. 

m 

5 

4 

3% 
9g 

9% 

6% 

9H 
12% 
12% 
12% 

7^ 

1 

7K 
4% 
1% 
Wa. 
M 

2.56 

27 

4.00 

7.00 

2.50 

5 

8 

5 

4 

10J4 
13% 

1 

2 

3.20 

28 

4.00 

7.00 

3.00 

5 

8 

5 

4 

1 

\vn 

3.88 

29 

4.00 

6.00 

3.00 

5 

8 

5 

4 

13% 

1 

1 

3.88 

30 

4.00 

5.50 

3.00 

5 

8 

5 

4 

10% 

13% 

1 

% 

3.88 

♦  Combination  impossible  with  percentage  of  cream  indicated. 

For  25-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  1%. 
For  30-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  1%. 
For  35-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  1%. 
For  40-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  2. 
For  15-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  2%. 

Fig.  62.— Ladd's  table. 


°l  % 


WHEY  CREAM  MIXTURES 
Whey  cream  mixtures  may  be  obtained  by  using  whey  as  a  diluent,  in 
place  of  the  boiled  water,  preferably  in  the  combinations  containing  low 
proteid  percentages.  Each  2  ounces  of  whey  replacing  an  equal  quantity 
of  water  in  a  twenty-ounce  mixture  will  raise  the  whey  proteid  percent- 
age 0.10,  and  will  increase  the  sugar  percentage  0.50.  The  total  sugar  per- 
centage is,  therefore,  the  amount  contributed  by  the  cream  and  fat  free 
milk,  which  is  indicated  in  the  last  column  of  the  table — on  the  reverse 
of  the  card, — plus  that  of  the  whey.  The  amount  of  dry  sugar  which 
must  be  added  to  make  the  desired  final  sugar  percentage  can  be  easily 
calculated  by  reference  to  the  following  table  : 

1  measure  of  dry  lactose  in  a  20-oz.  mixture  gives  2.00  per  cent,  of  sugar. 
11     11         n         ..         11  ii  11      1  no 

11     ■■         ii         ii         u  ..  ii         5o         «•  » 

(One  measure  is  approximately  one  level  tablespoonful.) 
Example.  If  in  formula  21  fourteen  ounces  of  whey  are  added  in  place 
of  the  siinie  quantity  of  water,  the  whey  proteids  are  increased  0.70  per 
cent.,  making  total  proteids  of  1.30  per  ceut.  The  sugar  contributed  by 
the  cream  is  0.78  ;  by  the  whey  3  50, — making  a  total  of  4.28.  The  desired 
percentage  of  sugar  is  6,  therefore  the  balance  of  1.72  per  cent,  may  be 
obtained  by  adding  a  little  short  of  one  measure  of  sugar. 

Whey  should  be  made  of  fat  free  milk,  and  should  be  heated  to  150°  F. 
(65°C.)  before  it  is  added  to  the  cream  mixture,  to  destroy  the  rennin  en- 
zyme. One  quart  of  fat  free  milk  will  yield  about  twenty-four  ounces  of 
whey. 

FOKMI'L.E  ON  WHICIt  THE  AVERAGE  Healthy  BaBV  MAY  BE  STARTED  : 

Premature X<>.  1  or  2        4-ii  months No.  24  or  2"> 

J-4  weeks No.  5,  8,  9  or  11        6-8  months No.  26  or  27 

1-2  months No,  12  or  13        8-9  months No.  JS 

2-4  months No.  19  or  2<) 

Table  for  Estimation  of  Fat  Percentages  in  Creams. 

One  quart  of  whole  milk,  of  4  per  cent,  fat,  will  yield  on  an  average, 

approximately  : 

Cream 1^  per  cent,  in  the  upper    8  OZ.  after  •'.  hours 

K)      "  "         "       11    "     ••     8  to  12  hours 

"      12       "  "  "         8    '•      '•     8  hours 

"       Hi       "  "  "  6     ■'      "      8  hours 

"      20       "  "  "         4    "      "     4  to  <i  hours 

Fig.  63.— Ladd's  tabic,  reverse  side. 


RULES 

FOR 

FEEDING 

Day  feedings  begin  6  a.m.,  end 

10  P.M. 

3 

4 

>> 

Is* 

a 

J 

0 

a 

3  ~ 

« 

- 

-^ 

0 

(4 

«a 

O 

t>0 

fq 

9 

-   - 

a 

M 
a 

"3 

■3 

43 
bo 

ft 

a 

O 

a 

z  3 

<1 

be 

u 

<0 

0  0 

O 
O 

5   bo 

a- 

u 

< 

ft 

ft 

< 

EH 

1  wk. 

2 

10 

1 

1 

10 

2    " 

2 

10 

1 

1% 

15 

4    " 

2 

9 

1 

2$ 

22^ 

6    " 

2% 
2% 
2% 
2% 

8 

1 

3 

24 

8    " 

8 

1 

3% 

26 

3  mos. 

7 

0 

4 

28 

4    " 

7 

0 

4% 

31% 

5    " 

3 

6 

0 

0% 

33 

6    " 

3 

6 

0 

61-? 

34% 

7    " 

3 

6 

0 

:'.;■., 

8    " 

3 

6 

0 

1 

12 

9    " 

3 

6 

0 

7 

42 

10  " 

11  " 

3 

3 

5 

5 

0 

0 

sn 

Si 

12    " 

3 

5 

0 

9 

45 

120 


ARTIFICIAL    FEEDING 


E*  O  Cm 

<!  W  <* 

Table 
3  per- 
Fat, 
Car- 
any 
Gur- 
ream 
on   a 
.    To 
cent, 
and  6 
select 
vhich 
e  re- 
otcids 
Head 
er   of 
t    top 
mt  of 
e   be- 
=  12: 
;arbo- 
full) 
ired ; 
essert- 
ream, 
isures 
[I.    B. 

000   e-<  0  oi 
=>  «?  °°    <  K  < 

«5 

X  -r  CO     1 
CO  CO*3<    " 

coo ' 
-  --c  X 

ji  cd"3< 

h  6  ps 

<  »  < 

CN 

to  0  0  1  co  m  0 

O  CO  tt     CO  -rf  CO 
CO  CO  "^  1  ^"  CO  Tp 

\    "  0 

oicosoo  nioo'ooo    E-d  K 
—              ChM   H«>r    03  -r_  p   p  p  cc    -<  oS  <! 
rS           |COcCTri'^co^'^co^|kOCC"^fopHQl 

\ 

1^-Slg"  "S-S^oou  1  gg| 

\     cc  ic:;tc  >     boshi.S"-i 

O 

COOO  0  no  0  co  0  0  CO  lO  0  000    Hocil 
co  00   ohoj   c  co  -r    co  -?-  co  1 0  co  cc    <;  ^  ^ 
co  co  ^  -^  co  -^  r^  co  -^  icco-^koco-^  E^^q 

COlOOMOO    OlOO     CO  O  O 
©*                   i-HCOCC      XOO     uOHCI     HCO1* 

**            coc^poicoco^-^co-^ioco^ 

niOolooo'Rn'S 
'-.  -  -.  ^  -.  ^  r<:  os  <\ 

OCO-^J*     COCO"^    PC^PlhO 

\  ^5  3:s^%-i^    . 

00 

000  ■■Sloo'woo 
0  i>  0   cc  00  00   co  0  0 
cooicojco'cNco  hj^COrP 

OlOO 
Or-JCJ 

O  CO  ^' 

COOO    COlOO 
CC  CC  -h    CO  ■*  cc 
lO  CO  ■*    CO  CO  •* 

og?'S2^l 

.  ~1       .      <    2i    < 

\     o 

\  ^'EScoOoS 

t> 

coico  ooor-oico 

•X>  lO  *^#    lO  t>  CO     «H  30  OC 

oi  oi  co  I  co  cm"  co  i  rr*  oi  co 

•000 
x  0  0 

HicO-r^ 

OlOO 

lO  rH  CN 
lOCO^f 

OOO 

COuOOOOOH  Q   af 
X  -^  CO  |  .-o  CO  X  |  .^  a*  < 

co  co  •*  lt>co^  .E^OhQ 

0 

000  'wicolooo 

OT"M     CO'  uO -T*   .  O  !>■  CO 

oi  oi  co  co  oi  co  j  tt  oi  co 

3iOO 

cc  x  aq 
-*c4co 

cooooiOo'cooo'coiOooooIeh  0  pj 
noqbrjM   p  cc  -r    co  -h  p    p  p  oc ;    <«  g  ^ 

lOCO-^     COCOTr  ice'eOTjH  |I>CO-rji|xcO^  j£hPh,0 

\     c 

orso 
s-c.de 

-HKiJ 

IO                  i-C  CI  O    1—  -V  OI 

woo 
x  >n  — j 

CO  CN  CO 

OOO 
<C  l>  CO 

^  c-i  co 

CO1O  0 

rH   X   0C 

looi  co 

COOOOiCO     COOOCOLCOOOO 

x  o  o   uO  —  o  i   i—i  co  -r    x  -r  '—_  ic  o  x 
idco-^.coco^  t^coTi<":t^co^"jxco^ 

e-  6  d 

<  OS  < 
rHpnO 

2 

™*           cn"  oi  ci 

OlOO 
0<NO 

cdoicd 

■000 
■-:  -r  cn 

CO  Ol  CO 

COlOO     OOO    COlOO  IcOOO    OlOO 
cc  10  -r    O  t^  CO    CO  CO  cc    co  0  p  1  p  IH  CN 
*^cn  co   io'c4co   lO  CN  co"  coco-^   i>co-<^ 

COOO 
cc  cc  — 
r-ico-rjJ 

CC  iO  O 

cc  cd-^i 

O  O  O  '  fH  o  d 

°.  ~.  °°     ■<   OS  < 

» co  ^  jfcH  p_  rj 

«"S 

(OOO 
I-"  OS  cc 

c4<h"  oi 

cooo 

X  rH  00 

oioi  oi 

OlOO 
0  CI  0 
cooico 

coooicoioooooUoioo'cooo 
htt  ci   x  10  -r   io  t^  cc    —  x  x  ;  00  0  0 
t3<cnco  U^oico  iidcNco   cocnco  [coco-* 

1           1           1 

OlOO 
p  rH  CN 
L-^CO-ctH 

COOO  ' CO  lO  o 

h:ch    x  -r  cc 

XCO-rF    CCco'-ci 

O  O  O  1  Eh   ^   OS 

o  ~  »   <:  ts  < 

»«*rHr-C 

fS 

O  O  O  '  CO  K0  O 
O  X  T     CO  OS  CO 
d  rH  oi  i  oi  rH  OI 

CO  00 

CO  *-l  CC 

co  c-i  c-i 

OlOO 
0  CI  0 
Tj>oico 

COOO'COiOo'oOOCOiOOICOOOlOiOolcOOO 

co  -r  ci   cc  ...  t    oi^cc   cc  x  x   cc  p  0  '  p  h  ci  i  p  cc  -r 

-C^' Ci  CC     id  CN  CO*  j  CO  CN  CO    CO  CN  CO*    1>C0  ^"  :  XCO^  jCOCOrf 

CO  'CC  O     o  OO 
CC  —  CC     p  CO  X 

oc"  CO  rr  I  cd  co"  ■*  | 

11 

T83 
1.65 
2.20 
2.50 
1.80 
2.40 

to  to  O  [CO  00 

HOIS      Jl  rH  CO 
CO  r-H  CN  j  CO  CN  CN 

OlOO  'cOOO  '  COlOO  [OOO 
lO  CI  O    HHC1     X  lO  -H     lO  i>  CO 

^oicoidcNco  idoicojcooico 

ccioocooooicco'cooo'coioo 

rH  X  X    X  O  O    lChCI    —  CC  -r     x  —  p 

r-oico  Jr>co-rji  jx'co-^i  oico^cr  iccico-^' 

O 

CO  OO  iCOtCO    000 
■~z  l-o  0    ::  c  m    0  x  ~* 

rHi-ic4    c4iHC4  IcQ  rH  oi 

CC  lO  O  1  CO  0  0 

-,C  Cr.CC  .  CO  rH  cc 
COrHCN    1-*  CNCN 

OiOOOOOCOLOOOOOCOifCrO'cOOOlOi-OO    COOO  ' 
OC1C    CO  rrr  Ol  j  CO  i-O  -r     Ol>cC    CO  X  X    CO  O  O    OH  01    'O  CO  -r 

i-ocmco"  icoico"  1  to  oi  co  choice  c^oico  .xco^  jOsco-rp  osco^  > 

©v 

OiCOcOOOlcOiCO 
lO  CO  CC     HlO  O    OO  CO  C-* 

^  r^  ^    CN  i-<  c4    CM"  r-i  C4 

OOO 
lC  X  -r 

COrHCN 

CO1OO 

■rfr-icsi 

CO  O  O     OlOO 
X  ^  -X    lO  oi  o 
-^oioi  ooico" 

COOO 

rH-H   CI 

co  oi  co 

COlOO  loo  p 

cocn'co  i-ioi  co 

CO  lO  o  1  CO  o  o 

rH  X  X      X  O  O 

cd  oi  co  1  cd  cd  -ni 

OlOO 

lO   rH   CI 

cico'-crM 

00 

CO  0  O    O  1(0  O  1  CO  O  O     CO  KO  0 
C"  Oi  —    O  :c  X     -^i.tO    :'  CO  CM 
rlrJy-4  1  oi  rH  rH     OI  — i  CM    CO*  rH  oi 

OOO  IcO  lO  0  '  CO  0  0 

O  X  rj<  ICS  C5  CC      CO  rH  CO 

■*  r-i  oi  l-rji  i-l  oi  id  oi  oi 

O  lO  O     CO  O  O 
p  CN  O     CO  ■*  OI 

cd  oi  co  cd  oi  co 

coioolooolcoiooccoo' 

CO  lO  -rr  .  o  r-  CC    CC  X  X     cc  o  p 

i>oico'|ccoico'[x'cNcdlo3cd'<c"j 

l> 

Oifto'rtoo'oico  'co 00 

i—l  O  -T'     X  CM-CO     uO  CO'  X     rH  L.O  O 
i-H  rH  i-H  I  i-H  rH  r-H  1 CN*  i-H  rH  ,  CO  rH  CM 

-oioolooo  'coioolcooo  'oioolcooo  'coioo 

00COCN    lOQOTJI     rHCncC     X  r- .00    uO  CN  O    rH  -rf  CN     X  p  — 

jx  r-i  oi  i-rpr-i  oi  iidrH  oi  ,ud  oioi  ,cooi  co  i>oi  co  .t>oico 

O  O  O  1  CO  lO  O 
uC  t-  p     --  X  X 

x  ci  cc   oi  oi  cd 

0 

!  000 

0  0)(N 

O  lO  O  '  CO  O  O 

cc  0  —    cc  ci  — 

OlOO 
p  CC  CO 

COOO  Icoioo  'OOO    COlOO  'cOOO  [OlOO    COOO  'COlOO  OOO 
ClCC     CC  CC  C 1     OXH     CC  OI  cc     CCr-X     O  CI  O     CC  TT  CI     CC  lO  -T     OL>-CC 

co  i-i  oi  |-cr  r-i  oi  iidr-ioi  .lo'r-ioi  jedoi  oi  i>oi  co'  (c^oi  co  Jccoico  loioi  co 

10 

CCiCO 

X  I--  0 

"r-H 

000 
oc.  :i 

r-5     "rH 

COvC  O 
-O-f 
CN-HrH 

COOO 
X  C  1  cc 
cirHrH 

oioo'ooo 

lO'  CO  X     rH  iO.  O 
CO  rH  rH    rji  rH  CN 

COifOO 

x  -o:  o) 

OOO 
in  X  -r 

id  i-i  oi 

COlOO 
rH  ~  CO 
cd  I--  oi 

COOOOiOo'cOOO    CCi.CO 
XrHX!iOC10    — _rrCl    X  p  -r 

cd  oi  oi  j  c^  oi  cd  ,  x'  oi  cd    x  ci  cc 

T 

CO  O  O  :  CO  uO  O 
CO  CO  X      CO  1-;  O 

OOO 
O  Oi  CI 
CN     'i-l 

-OlOO 

CC  O  -!■ 

cooo  'oioo 
co  ci  cc    o  :c  x 

CO  r-i  rH  1  Tj!  rH  r-i 

CO  O  O    COiOO 
CO  i.O  O     CO  CO  01 

i^rHoi  io»-Jo4 

OOO 

-  x  — 

COrHCN 

COlOO    COOOOiOOCOOO 
•-C  CC-  CO    CO  rH  0C     O  CI  CC     CC  -T  CI 

cdr-ioi  t>ioioi  iccoicd  xoico" 

K5 

OiCO 

m  -r  co 

coo  0  'rtino 
.—  —  ry:.    -^  l~  p 

OOO 
lO  p  c  1 

COiOOCOOOOlOOCOOO 

^  O  Hf     XCICC     iCCOX!rHpO 
COrHrHCOr-ir-iirjirHrHjidrHoi 

COiOo'oOOCOiOO'COOO     OlOO 
X  ICO  C 1     lO  X  ~r     rH  p  p     X  h  X     lO  CN  O 

id  r-i  oi   cd  r-i  oi  j  i-i  r-i  oi   r-i  oi  ci    x  ci  cc 

tN 

COOO 

OlflO  '  co  0  0 

04<0     CC  CO  X 
rH     •      "|rH      ■ 

CClOO 
CO  1-;  p 

oi     "r- 

OOO    COlOO  IcOOO     OlOO    COOO  'COlOO  'OOO    COlO  O    COOO 

ScScn    ceo—    CC  CI  CC    o  cc  x    ppp    cc  p  ci    pxp    ppp    COr-JOO 

CO      "r-i     CO  r-i  r-i  [rji  rH  r-i     id  r-i  r-i  ,iO'r-i  CN  j  CO  r-i  CN     t^  r-i  CN     t^  r-i  Ol'  ,  CO  CN  CN 

- 

COlOO 

, CI 

COOO 
30  M  — 

OiC  p 

COOO 

rH   CC    X 

ci 

CO  lOO    o  o  o 
X  t>  O    OOI  OI 

Oi     -r4|0O     "rH 

CO  HO  O    CO  O  O  1  O  uO'  O    (OOO    CO  lO  O    OOO  '  CO  uO  o 
—  O  -T     X  ?  1  CO     lO  CO  X     i—i  uO  O     X  CO  OJ     uCX-     —  Z~-^  'O 

^^^l^r-JrHJiCi-ii-H     COi-HCMjCOi-HOir^T-Hoi     Xr-01 

O 

*-  d 
f-HO 

CO  iC  p 

COOO 

cc  :c  -r 

O  lO  0  to  0  0 
0  -r  cc   p  p  x 
ci    '    '  ic-i 

icOiOO  lOOO     cOiOOCOOO     OiCO 

co  t*  o    o  cn  o  i    co  o  -r   co  cm  -o   o  co  x_ 

CO      'i-iW      'h   WhH  ilOHHiCOHH 

COOO 
CO  LC  0 
CO  I-H  ci 

CO  lO  O     OOO 

:c  cc  ci    o  X  -r 
r-i  r-i  oi  ,  X  r-  c  i 

0 

i-H 

cq 

CO 

** 

m 

CO 

c~ 

00 

Oi 

o 

rH 

I— 1 

i-H 

CN 

f-t 

MODIFICATION    OF    MILK  121 

Dr.  Maynard  Ladd,  of  Boston,  has  published  a  table  from  which 
almost  any  desired  formula  may  be  quickly  determined  with  reasonable 
aecuracy.  The  table  (Fig'.  02)  is  printed  upon  a  card  and  carried  in  the 
pocket  for  ready  references.  The  reverse  side  (Fig.  63)  gives  rules  for 
whey-cream  mixtures  (split  proteids),  suggestions  about  feeding,  ;ind 
estimations  of  fat  percentages  in  different  top  milks.  The  tables  are 
computed  on  the  basis  of  milk  which  contains  4  per  cent,  fat,  4.50  per 
cent,  sugar,  and  3.50  per  cent,  proteids,  and  are  used  as  follows : 

From  the  thirty  formula?  select  one  whose  fat,  sugar,  and  proteid 
most  nearly  approximate  the  desired  percentages  of  these  ingredients 
in  a  twenty-ounce  mixture.  Follow  the  line  of  this  formula  to  the  right 
to  find  the  quantity  in  ounces  of  cream  of  a  strength  indicated  at  the 
top  of  the  cream  column ;  also  the  necessary  quantity  of  skim-milk  in 
the  corresponding  milk  column ;  next  the  lime-water  for  a  five  per  cent, 
alkalinity ;  then  the  boiled  water  diluent,  and  lastly  the  measures 
(tablespoonfuls)  of  milk  sugar.  Obviously  to  prepare  a  mixture  of  more 
than  twenty  ounces  each  ingredient  must  be  proportionately  increased. 
See  last  column. 

H.  B.  Gurler,  of  DeKalb,  Illinois,  furnishes  to  physicians  a  table 
for  home  modification  of  his  certified  milk,  which  contains  fat  4  to  4.2 
per  cent. ;  proteids  3.4  to  3.8  per  cent. ;  sugar  4.6  to  5  per  cent.,  and 
cream  containing  fat  16  to  16.2  per  cent.  (Fig.  64). 

An  ingenious  chart  for  milk  modification,  designed  by  Dr.  T.  S. 
Westcott,  of  Philadelphia,  consists  of  two  revolving  cardboard  disks, 
with  numbers  so  arranged  that  by  simple  manipulation  the  relative 
quantities  of  ingredients  are  automatically  computed   (Fig.  65). 

Many  practitioners  who  have  not  had  previous  drill  cannot  spare  or 
will  not  take  the  time  to  work  out  these  formula?  for  themselves.  For 
their  assistance  many  rules,  approximately  correct,  in  tablespoonfuls  and 
ounces,  have  been  suggested.  A  seven-panelled  glass  graduate,  called 
the  "  Materna"  (Fig.  66),  has  been  presented  by  a  New  York  firm,  on 
each  panel  of  which  markings  indicate  the  necessary  amount  of  milk, 
sugar,  water,  lime-water,  and  cream,  respectively,  to  secure  certain  per- 
centages, which  are  also  marked  on  the  panel.  Two  objections  should  be 
noted :  its  routine  employment  may  tend  to  divert  the  physician  from 
thinking;  the  other  is  suggested  by  the  directions  for  feeding  by  age  of 
patient,  which  is  about  as  uncertain  a  standard  as  color  of  hair.  Some 
physicians  employ  slips,  carrying  printed  directions  to  nurse  or  mother, 
so  arranged  that  they  may  be  changed  easily  to  meet  the  requirements 
of  particular  cases. 

Dr.  H.  D.  Chapin  has  devised  a  method  of  removing  the  top  milk 
from  the  milk  bottle  for  home  modification,  which  he  claims  is  especially 
applicable  to  the  needs  of  the  nursery.  He  employs  a  small  tin  dipper 
with  a  vertical  wire  handle  (Fig.  67).  This  dipper  holds  one  ounce  of 
cream  or  one  ounce  of  granulated  sugar,  and  a  dipper  and  one-half  rep- 
resents an  ounce  of  milk  sugar.  As  a  result  of  experiment  and  numerous 
assays,  Dr.  Chapin  has  found  that  if  nine  ounces  are  removed  from  the 


122 


ARTIFICIAL    FEEDING 


top  of  the  bottle  and  mixed  together  the  product  represents,  with  great 
uniformity,  twelve  per  cent,  cream.     To  get  eight  per  cent,  cream  it  is 


Fig.  65.— Westcott's  chart. 


only  necessary  to  remove  and  mix  sixteen  ounces  from  the  top  of  the 
bottle.  The  above  is  applicable  only  to  milk  which  has  been  bottled  long 
enough  to  allow  segregation  by  gravity. 


Fig.  66.— Materna. 


Fig.  67.— Chapin's  dipper. 


To  prepare  twenty-four  fluidounces  of  food  containing  three  per 
cent,  fat,  one  per  cent,  proteids,  and  six  per  cent,  sugar,  use  six  fluid- 


HOME    MODIFICATION'    OF    MILK 


123 


ounces  of  twelve  per  cent,  cream,  < ■  i •_- J 1 1 « •  < * 1 1  iluidonnees  of  diluent,  and 
one  and  one-fifth  ounces  of  sugar.  Similarly,  to  prepare  forty  fluid- 
ounces  of  food  containing  four  per  cent,  fat,  two  per  cent,  proteids,  and 
seven  per  cent,  sugar,  use  twenty  nuidounces  of  eight  per  cent,  cream, 
twenty  fluidounces  of  diluent,  ;md  two  ounces  of  sugar. 

Dr.  J.  F.  Connors  has  arranged  a  key,  applicable  to  the  home  modi- 
fication of  bottled  milk  by  the  Chapin  "  dipper"  method,  concerning 
which  the  author  says:  "  To  make  up  any  desired  percentage  mixture: 
(1)  Look  in  the  proteid  column  for  desired  percentage,  using  the  one 
nearest  to  it.  (2)  Move  in  a  horizontal  line  to  the  left  until  the  desired 
percentage  of  fat  is  reached  or  near  it.  (3)  The  heading  of  the  fat 
column  tells  what  kind  of  milk  is  to  be  used;   and  (4)  the  first  column 


Proportions  of 

Milk  and 

Per 

Per 

Diluent  in 

Per  Cent.  Fat 

Cent. 

Cent. 

Feeding 

Proteids 

Sugar 

MIXTURE9 

4-> 

■w 

^ 

+5 

_j 

- 

• 

p, 

p. 

O 

O 

53  ^-> 

a 

CD 

4>  — 

a 

0J 

<w-~ 

<D 

0 

0 

ai 
to 

CO 

o3 

P." 

P'a 

ftl 

ft-~ 

KB 

a* 

0 

*71 

CO  0J 

00  P 

°  — 

ci  a 

~t>  <a 

to  a 

13 

0   . 

.„ 

M 

«"3 

+J-0J 

""io 

""H  a) 

""I/o 

1-1  0) 

■5  0 

|fl 

a 

a 

<5 

% 

as 

1    . 

O    QJ 

to  <D 

sa 

•'  > 

CO 

N  ?! 

vi  OJ 
gj 

°a 

3^ 

.  0J 

n  a 

O-JS 

°a 

-0J 

•a  ft 

»*  0J 

-  0 

a  °< 

it 

<?> . j- 

OO  \N 

^'■S 

3;3 

HM 

s 

S 

a  p- 

73  Q. 

f-t 

b 

o_r 

P^H 

pci 

0,0 

ftco 

cLm 

(£•* 

0  H 

a5 

03 

S1-1 

o-*1 

O^ 

0s-" 

o~-^ 

ow 

o  -* 

Ow 

C  s 

PL, 

Ph 

cc 

O 

&H 

H 

H 

H 

Eh 

EH 

^ 

ft 

1 

7 

.13 

.50 

.75 

1.00 

1.25 

1.50 

1.75 

2.00 

.41 

.50 

1 

6 

.14 

.57 

.86 

1.14 

1.43 

1.71 

2.00 

2.30 

.46 

.57 

1 

5 

.17 

.67 

1.00 

1.33 

1.67 

2.00 

2.34 

2.67 

.54 

.67 

1 

4 

.20 

.80 

1.20 

1.60 

2.00 

2.40 

2'.  80 

3  20 

.65 

.80 

1 

3 

.25 

1.00 

1.50 

2.00 

2.50 

3.00 

3.50 

4.00 

.81 

1.00 

1 

2 

.33 

1.33 

2.00 

2.67 

3.33 

4.00 

4.66 

5.33 

1.08 

1.33 

2 

3 

.40 

1.60 

2.40 

3.20 

4.00 

4.80 

5.60 

6.40 

1.30 

1.60 

1 

1 

.50 

2.00 

3.00 

4.00 

5.00 

6.00 

7.00 

8.00 

L.63 

2.00 

5 

3 

.62 

2.50 

3.75 

5.00 

6.25 

7.50 

8.75 

10.00 

2.03 

2.50 

2 

1 

.67 

2.67 

4.00 

5.33 

6.67 

8.00 

9.33 

10.67 

2.16 

2.67 

3 

1 

.75 

3.00 

4.50 

6.00 

7.50 

9.00 

10.50 

12.00 

2.44 

3.00 

Fig.  68.— Dr.  Connor's  table. 

of  the  table,  what  proportion  of  the  feeding  mixture  the  milk  must  be. 
(5)  In  preparing  the  food  use  good  bottled  milk  and  dilute  all  or  part 
of  it,  depending  on  the  quantity  of  food  to  be  made  up.  Mixtures  made 
from  poor  milk  will  be  one-fourth  weaker,  from  Jersey  milk  one-fourth 
stronger.  (6)  The  sugar  column  shows  the  percentage  of  sugar  in  the 
diluted  milk ;  one  part  sugar  to  fifty  parts  food  add  two  per  cent. ;  to 
thirty-three  parts  three  per  cent. ;  to  twenty-five  parts  four  per  cent. ; 
and  to  twenty  parts  five  per  cent.  Two  even  tablespoonfuls  of  granu- 
lated sugar  or  three  of  milk  sugar  equal  one  ounce  (Fig.  68). 

In  regard  to  all  devices  it  is  suggested  that  the  young  physician  first 


124  .      ARTIFICIAL    FEEDING 

form  the  habit  of  thinking  and  formulating  for  himself,  after  which  he 
may  best  judge  of  their  value.  Whatever  method  be  employed,  one 
essential  must  never  be  lost  sight  of  in  order  to  secure  even  approximate 
accuracy  of  ingredient  percentages, — viz.,  a  predetermination  of  the 
gross  constituents  of  the  milk  used.  Certified  milk  guarantees  certain 
percentages.  Centrifugalized  cream  may  be  ordered  of  definite  fat  per 
cent,  and  fat-free  milk  may  be  obtained  by  siphoning  the  lower  half  of 
the  bottle  after  it  has  creamed.  Milk  of  unknown  quality  may  be  tested 
by  the  methods  described  on  page  100. 

In  substitute  feeding  the  aseptic  care  of  the  bottle,  nipples,  and  all 
utensils  cannot  be  unduly  emphasized.  The  familiar  death-trap  known 
as  the  long  tube  nursing  bottle  has  at  last  attracted  the  attention  of 
legislators,  so  that  in  some  localities  not  only  the  use  but  also  the  sale  is 
prohibited  by  law. 

For  home  modification  the  mother  or  nurse  must  be  instructed  in 
regard  to  all  details  and  supplied  with  the  necessary  utensils.  These 
include  a  good  ice-box,  two  siphons  (made  by  bending  glass  tubing), 
sterilizer  or  pasteurizer,  thermometer  registering  to  212°  F.  (100°  C),  a 
dozen  graduated  feeding  tubes  (large  mouth  without  shoulder  with 
small  lip),  bottle  brushes,  absorbent  cotton,  straining  gauze,  nonab- 
sorbent  cotton  for  stoppers,  mixing  pitcher,  eight-ounce  graduate  glass 
funnel,  tall  cup  for  warming  bottle,  six  black  rubber  nipples  (to  fit 
mouth  of  tubes,  reversible  for  cleaning),  bicarbonate  of  soda  and  boric 
acid. 

Lime-water  should  be  kept  in  corked  bottles.  Milk-sugar  solution 
should  be  prepared  fresh  for  each  day's  supply.  The  supply  of  food 
may  be  prepared  once  or  twice  in  the  twenty-four  hours,  dependent  upon 
the  time  of  milk  delivery  and  number  of  tubes  to  be  handled.  The  milk 
should  always  be  kept  on  ice  before  and  after  preparation. 

All  bottles  and  utensils  should  be  washed  with  hot  soap-suds,  then 
dozen  graduated  feeding  tubes  (large  mouth  without  shoulder  with 
out  with  soap  and  water,  rinsed  and  kept  in  a  solution  of  soda  or  boric 
acid  until  again  needed.  Milk  tubes  when  filled  should  be  stoppered 
with  nonabsorbent  cotton  so  that  in  cooling  the  air  may  pass  through. 
After  warming  to  about  100°  F.  (38°  C.)  by  standing  the  bottle  in  a 
cup  of  warm  water,  the  cotton  is  replaced  by  the  nipple. 

After  nursing,  any  food  remaining  in  the  bottle  must  be  thrown  away. 
Flies  should  never  be  allowed  to  touch  food,  utensils,  or  baby.  Of 
course,  the  nurse  will  never  touch  the  nipple  with  her  lips.  The  tem- 
perature of  the  milk  may  be  tested  by  allowing  a  few  drops  to  fall  upon 
the  back  of  the  hand.  The  bottle  should  be  held  inverted  in  the  hand 
during  the  feeding  so  that  the  babe  will  not  suck  air  (Fig.  69).  If  the 
milk  flow  be  too  free  the  nipple  may  be  withdrawn  from  time  to  time 
so  that  about  twenty  minutes  is  consumed  in  the  feeding,  during  which 
the  babe  would  better  be  on  the  arm  or  lap  of  the  nurse.  If  the  milk 
does  not  drop  freely  enough  more  holes  should  be  made  in  the  nipple 
by  means  of  a  hot  needle. 


SOME   DIFFICULTIES  IN  ARTIFICIAL- FEEDING        L25 

The  rules  for  feeding,  as  to  regularity,  number,  and  length  of  in- 
tervals, should  be  about  the  same  as  those  given  for  infants  at  the  breast 
(page  87).  Water  between  feedings  is  generally  required  and  to  a 
ravenous  infant  should  be  freely  given.  The  water  should  be  boiled  and 
cooled,  and  may  be  given  from  either  bottle  or  spoon. 

As  a  rule,  artificial  feeding  in  the  normal  vigorous  babies  should 
be  begun  with  formulas  representing  low  percentages.  Especially  is 
this  true  of  the  proteids.  Taking  average  mother's  milk  as  a  standard 
the  percentage  of  sugar  may  be  about  the  same,  the  fats  about  half,  and 
the  proteids  about  one-third,  remembering  that  temporary  error  on  the 
side  of  underfeeding  is  easier  of  correction  than  the  more  common 
mistake  of  overfeeding. 

Since  the  milk  of  other  mammals  somewhat  closely  resembles  the 
human  product,  and  its  abundant  supply  is  co-extensive  with  man,  the 


Fig.  69. — Correct  position  in  artificial  feeding. 

question  may  again  be  raised  why  the  multiplicity  of  baby  foods,  espe- 
cially when  it  is  known  that  milk  is  the  cheapest.  In  this  instance 
"commercial  enterprise"  will  not  serve  as  an  answer,  for  the  demand 
must  have  existed  to  which  the  latter  has  responded.  Without  further 
argument  it  is  quite  evident  that  cow's  milk  has  failed  to  fulfil  all  the 
requirements  of  substitute  feeding,  and  in  their  need  both  laity  and  pro- 
fession have  turned  to  other  sources.  Some  of  the  objections  to  cow's 
milk  as  ordinarily  obtained  by  the  consumer  have  been  mentioned  (the 
high  percentage  of  proteids,  low  percentage  of  sugar,  reaction  and  in- 


126  AKTIFICIAL    FEEDING 

fection).  These  objectionable  features  having  been  overcome,  partly 
by  the  improved  hygiene  in  production  and  handling,  and  partly  by  the 
elaborate  percentage  modification  previously  referred  to,  the  question 
of  substitute  feeding  would  appear  to  have  reached  a  solution.  In  this 
case  the  only  obstacles  to  its  universal  adoption  would  seem  to  be 
the  cupidity  of  the  manufacturer  of  baby  foods  and  the  credulity  of  the 
purchaser.  In  fact,  this  is  the  view  taken  by  many  conscientious  baby 
feeders.  "Were  the  solution  of  this  problem  attained,  however,  the  most 
eminent  observers  and  thinkers  would  not  be  found  still  struggling  with 
it.  As  it  is,  medical  literature  and  reports  of  society  proceedings  teem 
with  discussions  upon  this  ever-interesting  subject.  It  is  known  that 
cow's  milk,  modified  never  so  wisely,  cannot  be  made  to  suit  all  require- 
ments of  infant  digestion.  Many  infants,  no  doubt  the  majority,  thrive 
on  it,  and  the  careful  modification  of  its  constituents  has  largely  in- 
creased this  number.  There  still  remains,  however,  an  appreciable  per- 
centage of  cases  in  which  the  proteids  of  cow's  milk  are  not  tolerated, 
and  occasionally  the  fats  are  nonassimilable. 

The  lowest  reduction  possible  in  the  laboratory  manipulations  of 
cow's  milk  still  leaves  the  proteids  as  0.22  per  cent.  It  is  hardly 
necessary  to  state  that  no  infant  will  long  survive  this  reduction.  A 
higher  percentage  of  digestible  proteids  is  absolutely  essential  to  nutri- 
tion and  growth.  As  shown  in  a  previous  chapter,  their  place  cannot 
be  filled  by  any  known  substitute.  Moreover,  the  albuminoids  of 
mother's  milk  differ  essentially  from  those  of  cow's  milk.  By  taking 
two  watch-crystals,  filled  with  a  weak  solution  of  acetic  acid,  and  letting 
fall  into  them  from  a  height  of  two  or  three  inches  a  drop  of  mother's 
milk  and  a  drop  of  cow's  milk  respectively,  one  of  these  differences 
becomes  apparent, — the  casein  of  mother's  milk  coagulating  in  light, 
loose  flocculi,  which  disseminate  throughout  the  fluid ;  that  of  the  cow 's 
showing  dense  and  heavy  curds  which  fall  to  the  bottom.  In  other 
words,  the  proportion  of  proteid  coagulable  by  acid  (casein)  is  much 
greater  in  cow's  milk  than  in  human  milk.  Whereas  the  proportion  of 
calcium  casein  to  lactalbumin  in  breast  milk  is  only  1  to  2,  in  cow's 
milk  it  is  nearly  7  to  2.  In  other  words,  while  the  casein  of  cow's 
milk  is  nearly  four  times  that  of  breast  milk,  the  noncoagulable  proteids 
(lactalbumin,  laetoglobulin,  etc.)  amount  to  less  than  half  those  found 
in  breast  milk. 

It  seems  hardly  necessary  to  repeat  the  statement  that  the  finely 
subdivided  precipitate  of  breast  milk  favors  the  action  of  the  digestive 
secretions,  while  the  dense  curds  of  cow's  milk  resist  this  action  so  long 
that  fermentation  often  ensues,  with  all  its  train  of  intestinal  disturb- 
ances. Wroblewski  demonstrated  that  human  casein  retains,  during 
digestion,  its  nuclein  in  solution;  it  is  fully  digested;  while  in  cow's 
casein  the  nuclein  is  not  fully  digested;  a  "paranuclein"  is  deposited 
undissolved  and  undigested. 

From  his  studies  of  nucleon  Siegfried  found  that  cow's  milk  contains 
0.057  and  woman's  milk  0.124  per  cent,  nucleon.     In  cow's  milk  the 


REASONS    FOR    INTOLERANCE    OF    COW'S    .MILK       127 

phosphorus  of  the  nucleon  is  only  six  per  cent,  of  the  total  amount  of 
phosphorus  contained  in  the  milk;  in  woman's  milk  it  is  more  than 
forty-one  per  cent. 

Practically  all  the  phosphorus  in  human  milk  is  in  organic  combi- 
nation (nucleon  and  caseinogen).  Concerning  this  point  Salkowski  says  : 
"  These  conditions  are  evidently  of  the  greatest  moment  in  the  nutrition 
of  the  nursling.  As  the  development  of  the  bones  is  more  rapidly  accom- 
plished in  the  nurslings  fed  on  woman's  milk  than  in  those  fed  on  cow's 
milk,  the  probable  conclusion  is  this:  that  nucleon  has  an  important  part 
in  the  absorption  and  assimilation  of  phosphorus.  The  same  should  be 
said  of  calcium,  which  also  combines  Math  nucleon.  Although  woman's 
milk  contains  less  calcium  than  cow's  milk,  more  calcium  is  utilized  and 
the  nucleon  is  evidently  an  important  factor  in  its  absorption. ' '  Woman 's 
milk  contains  more  lecithin  than  that  of  other  mammals,  a  fact  of  great 
importance,  as  lecithin  is  necessary  to  the  development  of  the  brain  and 
nervous  system,  and  is  an  important  constituent  of  all  cells. 

Prom  the  above,  some  explanation  may  be  drawn :  First,  as  to  why 
some  infants  cannot  be  induced  to  tolerate  cow's  milk  in  any  of  its  pos- 
sible modifications ;  second,  why  normal  nutrition  cannot  be  maintained 
even  though  digestive  toleration  be  established.  The  assertion  that  strong 
children  may  tolerate  cow  proteids,  even  though  not  greatly  reduced, 
does  not  apply,  for  the  reason  that  it  is  for  the  weakly  infant  with  the 
feeble  digestion  that  the  skill  of  the  physician  is  sought.  It  was  formerly 
believed  that  some  of  the  other  mammals  furnish  a  more  digestible  pro- 
teid  than  the  cow ;  hence  the  goat,  ass,  and  mare,  respectively,  have  been 
extolled  for  this  quality  of  their  product.  Clinical  observation,  how- 
ever, shows  little  advantage  over  cow's  milk.  The  following  analyses 
by  Konig  give  the  relative  percentages  of  constituents : 

Casein  Albumin  Fat  Sugar  Ash 

Goat   3.20         1.09  4.78  4.46  0.76 

Ass    0.67          1.55  1.64  5.99  0.51 

Ewe    4.97         1.55  6.86  4.91  0.39 

Mare    . 1.24         0.07  1.21  5.67  0.35 

For  feeble  or  impaired  digestion,  on  account  of  the  intractability  of 
casein,  partial  predigestion  of  the  milk  has  been  practised;  thus,  the 
addition  of  pancreatic  extract,  commonly  used  in  Fairchild's  process, 
wrongly  called  "peptonization,"  has  occasionally  proved  efficacious. 

Fairchild's  tubes  contain  extractum  pancreatis  and  sodium  bicar- 
bonate in  sufficient  quantity  for  the  treatment  of  one  pint  of  cow's  milk. 
The  milk  is  first  gently  warmed,  then  the  contents  of  the  tube  stirred  in, 
and  the  mixture  brought  to  a  boil  in  ten  minutes.  The  boiling  arrests 
the  "peptonizing"  process  and  destroys  the  ferment.  This  partial  con- 
version renders  the  casein  more  flocculent  and  less  coagulable  in  the 
stomach,  and  allows  its  early  escape  into  the  intestine  where  the  digestive 
process  in  early  infancy  rightly  belongs.  That  such  efforts  at  pre- 
digestion may,  if  prolonged,  prove  pernicious  is  evident  in  view  of  the 


128  ARTIFICIAL    FEEDING 

seventh  essential  (page  111),  since  it  defeats  nature's  methods  of  gastric 
development,  from  the  lack  of  muscular  and  secretory  stimulus  afforded 
by  the  presence  of  curds  of  calcium  paracasein  and  free  paracasein  in 
the  stomach. 

Koumiss,  matzoon,  and  kephir-milk  are  merely  expressions  of  an 
effort  to  rid  cow's,  mare's,  and  goat's  milk  of  this  offending  substance 
by  changing  calcium  casein  into  the  lactate  or  some  other  acid  salt  of 
casein  before  ingestion,  so  that  dense  coagulation  in  the  stomach  by  the 
action  of  rennin  is  prevented. 

Decaseinized  Milk. — Into  a  pint  of  warm  milk  stir  a  teaspoonful  of 
Fairchild's  essence  of  pepsin.  After  coagulation  (about  twenty  minutes) 
break  up  the  clot  with  a  fork,  and  strain  through  thin  muslin  without 
pressure.  The  whey  containing  soluble  proteids,  lactose,  and  salts,  may 
be  enriched  by  the  addition  of  cream  and  sugar  of  milk,  while  the  de- 
ficient albuminoids  may  be  supplied  from  egg  albumin.  Egg  white  is 
also  successfully  used  in  laboratory  modification  for  infants  intolerant 
of  cow  casein.  A  liberal  estimate  gives  one  per  cent,  albuminoid  from 
the  white  of  one  egg  in  a  pint  mixture,  so  that  a  prescription  might  be 
written  and  made  up  as  follows : 

B 

Fat  per  cent 3     Cream  ( 16%)  ounces  6 

Lactose  per  cent 7     Milk  sugar,  tablespoonfuls  6 

Albuminoid  per  cent 2     Large   egg  whites  2 

Water,  ad  per  cent 100     Boiled  water,   qs.   ad  oz  32 

Alkalinity  per  cent 

Number  of  feedings    8 

Amount  at   feeding    oz.     4 

In  the  above  prescription  some  of  the  proteids  and  lactose  are  still 
retained  from  the  cream,  necessary  to  secure  the  three  per  cent.  fat.  The 
egg,  as  a  source  of  albumin,  so  long  recognized  as  valuable  in  tiding  over 
critical  periods  of  indigestion  in  infants,  has  not  received  the  considera- 
tion it  deserves.  Its  ready  solubility,  its  sterility  when  fairly  handled, 
its  richness  in  albumin,  steady  supply,  and  cheapness,  all  commend  it; 
while  its  ready  digestibility  and  assimilation  by  the  most  intolerant  diges- 
tive tract  have  long  been  recognized  facts.  The  objection  that  it  is 
''troublesome  and  messy"  would  apply  equally  well  to  most  of  the  food 
preparations.  An  objection  that  sometimes  it  induces  ill-smelling  dejec- 
tions, might  be  met  by  the  suggestion  that  a  small-  quantity  of  sulphu- 
retted hydrogen  is  innocuous,  or  the  quantity  of  egg  in  the  mixture 
may  be  reduced.  As  egg  albumin  does  not  fill  the  entire  role  of  proteids 
in  metabolism,  and  since  it  lacks  the  coagulability  with  rennin  so  essen- 
tial to  gastric  development,  it  should  never  be  employed  to  the  entire 
exclusion  of  casein  for  long  periods,  but  merely  to  tide  over,  or  to  help 
out,  in  conditions  of  intolerance  to  cow  proteids. 

For  similar  reasons  the  use  of  whey  alone  as  a  source  of  proteids 
should  never  be  protracted  beyond  the  period  of  emergency. 

The  yolk  of  egg  may  profitably  be  employed  in  feeding  mixtures  for 


DECALCIFIED    MILK  129 

infants  who  are  intolerant  of  milk  fat,  the  volatile  acids  of  which  often 
prove  irritating.  The  calorie  fat  value  of  the  average  yolk  is  claimed  to 
equal  that  of  one  ounce  of  20  per  cent,  cream.  It  also  contains  more 
lecithin  and  considerably  less  butyric  and  other  volatile  acids.  As  the 
average  yolk  weighs  three  drachms,  half  a  draclmi  in  a  two  and  a  half 
ounce  feeding  would  represent  1  per  cent,  of  fat.  This,  with  an  appro- 
priate amount  of  milk  sugar  added  to  whey,  may  be  borne  by  a  young 
infant  whose  digestive  tract  is  intolerant  of  butter  fat.  Its  nutrient 
value  has  been  demonstrated  beyond  question. 

DECALCIFIED    MILK. 

Since  the  heavy  coagulability  of  cow  proteids  is  held  largely  respon- 
sible for  the  dyspepsia,  their  reduction  will  frequently  relieve  it,  but 
not  always.  A  little  reflection  may  explain  one  of  the  anomalies  most 
perplexing  to  those  feeders  who  pin  faith  to  the  efficacy  of  curd  reduction 
through  extreme  dilution  with  water.  If  in  a  given  quantity  of  cow's 
milk  a  more  or  less  dense  curd  of  calcium  paracasein  be  precipitated  by 
the  rennin  and  acid  of  the  stomach,  it  is  probable  (from  its  behavior 
in  vitreo)  that  a  diminution  in  the  mere  quantity  of  calcium  casein,  the 
rennin  and  acid  remaining  the  same,  will  result  in  a  denser  curd  forma- 
tion, although  in  lessened  amount.  This  is  seen  by  the  persistence  in  the 
stools  of  undigested  curds,  even  though  the  food  be  reduced  to  merely 
weak  cream,  sugar  and  water.  This  fact  may  help  to  explain  the  fre- 
quent improvement  in  digestion,  and  the  disappearance  of  curds  from 
the  stools  when  the  milk  content  of  the  food  is  notably  increased;  also 
the  results  claimed  by  M.  Budin,  of  Paris,  who  for  years  has  fed  ivhole 
milk,  on  the  ground  that  the  dilution  of  cow's  milk  is  one  cause  for  the 
appearance  of  curds  in  the  stools.  To  secure  not  only  toleration,  but 
digestion  and  assimilation  of  the  cow  casein,  in  amounts  sufficient  for  a 
balanced  nutrition,  would  appear  to  be  the  kernel  of  this  much  discussed 
subject. 

Attenuation  of  the  calcium  paracasein  curds  through  the  mechanical 
action  of  cereal  gruels,  so  long  advocated  by  Jacobi  and  recently  de- 
monstrated by  Chapin,  has  been  widely  endorsed  both  in  this  country 
and  Europe. 

Since  the  large  quantity  of  lime-salts  is  held  responsible  for  the  dense 
calcium  paracasein  curds  of  cow's  milk,  it  has  been  suggested  by  Dr. 
A.  E.  Wright,  of  England,  that  a  portion  of  the  calcium  salts  be  pre- 
cipitated by  sodium  citrate  (a  salt  not  foreign  to  milk),  and  thus  secure 
softer  paracasein  curd  in  the  infant  stomach.  Its  action  is  demonstrated 
by  Dr.  P.  J.  Poynton,  of  London,  as  follows :  Into  each  of  two  test-tubes, 
Nos.  1  and  2,  is  placed  one  ounce  of  cow's  milk,  five  drops  of  rennet,  and 
five  drops  of  a  0.5  per  cent,  solution  of  hydrochloric  acid.  Into  Xo.  2  is 
also  placed  three  grains  of  sodium  citrate.  After  standing  an  equal 
length  of  time,  No.  1  exhibits  a  dense  clot ;  Xo.  2  a  very  fine  clot,  the 
fluid  showing  greater  translucency  than  in  Xo.  1.  Dr.  Poynton,  at  Great 
Ormond  Street,  and  Dr.  J.  W.  Vanderslice,  at  Chicago,  are  using  the 

9 


130  ARTIFICIAL    FEEDING 

sodium  citrate  in  their  out-patient  feeding  with,  apparent  success.  Modi- 
fication of  the  curd  may  be  secured  by  varying  the  quantity  of  sodium 
citrate  used,  so  that,  within  certain  limits,  the  density  of  the  curdling 
is  under  control. 

For  a  moderate  degree  of  disturbance  one  grain  of  sodium  citrate 
to  the  ounce  of  milk  is  used ;  for  more  severe  grades,  two,  three,  or  even 
five  grains  may  be  added.  In  practice  the  mother  is  instructed  as  to  the 
proper  dilution  of  the  milk,  and  the  proportions  of  cream  and  sugar  for 
each  bottle.  In  addition,  she  is  given  a  bottle  of  "medicine"  from  which 
one  teaspoonful  is  to  be  added  to  the  baby's  bottle  before  feeding.  This 
"medicine"  is  an  aqueous  solution  of  sodium  citrate;  one,  two,  or  three 
grains  to  the  teaspoonful,  according  to  the  prescriber's  judgment,  based 
upon  the  evidences  of  casein  indigestion. 

The  flexibility  of  this  method  of  feeding  commends  it,  since  by  in- 
creasing the  strength  of  the  "medicine"  the  quantity  of  milk  may  be 
augmented  to  meet  the  requirements  of  nutrition  with  lessened  danger 
of  casein  indigestion. 

As  toleration  and  gastric  vigor  are  developed,  the  sodium  citrate  may 
be  gradually  reduced  and  finally  withdrawn. 

It  has  been  fashionable  of  late  to  decry  the  cereals  as  a  source  of  the 
constituents  for  substitute  feeding,  and  not  without  some  reason,  as 
the  weazened  infant,  starved  on  starch,  and  the  over-fatted,  rhachitic, 
sugar-fed  baby  are  familiar  pictures.  From  the  fact,  early  established  by 
the  physiologists,  that  the  salivary  and  pancreatic  secretions  of  young  in- 
fants show  limited  amylolytic  power,  it  was  believed  by  many  that  starch 
should  have  no  place  in  the  diet  of  the  infant.  Indisputable  clinical  evi- 
dence, however,  has  demonstrated  that  a  limited  amount  of  well-cooked 
starch,  in  the  form  of  cereal  gruels  and  jellies,  when  mixed  with  milk, 
is  not  only  tolerated,  but  favors  nutrition:  probably  on  account  of  its 
own  partial  conversion  by  the  secretions,  and  partly  through  its  influence 
in  preventing  the  too  dense  coagulation  of  the  cow  proteids.  Dextrini- 
zation  of  gruels  (Appendix)  undoubtedly  adds  to  their  food  value. 
Analysis  of  barley  water,  given  below,  affords  no  explanation  for  the 
nutritive  value  it  displays  in  many  pathologic  conditions  in  which,  for  a 
time,  it  is  the  only  food  ingested. 

Water     99.27 

Fat    002 

Albuminoids    0.03 

Starch    0.60 

Sugar    0.05 

Ash     0.03 

Many  of  the  so-called  baby  foods  contain  little  more  than  starch,  and 
on  that  account  cannot  be  too  severely  criticised ;  but  the  practice  some- 
what in  vogue  of  denouncing  the  entire  array  of  proprietary  foods  on 
that  account  is  thoughtless  and  unjust. 

There  is  enough  reason  for  the   condemnation   of  the  majority   of 


PROPRIETARY    FOODS 


l;l 


these  foods  because  of  the  excess  or  deficiency  of  some  constituents,  but 
each  should  be  judged  upon  its  merits.  On  the  other  band,  there  is  much 
to  recommend  in  some  of  these  preparations,  since  intelligent  manipu- 
lation, by  supplying  a  deficiency,  may  convert  a  patent  preparation 
into  a  most  valuable  adjunct  in  substitute  feeding. 

The  multitude  of  preparations  may  be  divided  into  four  general 
classes,  as  to  their  composition,  mode  of  preparation,  etc. : 

(1)  Milk  foods,  which  consist  wholly  or  partly  of  milk,  with  or  with- 
out the  addition  of  other  ingredients,  all  or  a  portion  of  the  water  having 
been  evaporated. 

(2)  So-called  dextrinized  foods,  derived  from  cereal  flour,  in  which 
the  starch  is  partly  converted  by  cooking  and  its  own  diastase,  the  great 
bulk,  however,  remaining  as  starch. 

(3)  So-called  Liebig's  foods,  in  which  the  diastasic  action  of  malt 
is  secured  by  its  admixture  with  the  ground  cereal.  It  is  then  submitted 
to  heat,  with  the  result  of  partial  or  entire  conversion  into  dextrin  and 
maltose. 

(4)  A  combination  of  Class  2  or  3  with  milk,  meat  juice,  or  egg 
albumin. 

A  list  of  a  few  of  the  preparations  in  our  market,  with  their  analyses, 
is  hereby  tabulated. 

Composition  of  some  infant  foods  as  prepared  for  the  nursing  bottle 
in  comparison  with  mother's  milk.  Prepared  according  to  directions  for 
infants  of  six  months : 


Mother's  milk1 

Cow's  milk1 

Condensed  milk2 

Peptogenic  milk  powder4  . . 

Milkine3 

Malted  milk4 

Mellin's  food4 

Nestles  food4 

Imperial  granum4 

Eskay's  albuminized  fond5. 


13.26 

12.61 
5.18 

13.97 
8.09 
7.43 

12.00 
7.24 
S.47 

11.33 


& 


4.13 
3.75 
0.53 
4.38 
0.59 
0.68 
2.85 
0.36 
1.54 
4.16 


g  6* 


2.00 
3.76 
0.65 
2.09 
1.12 
1.15 
2.62 
0.36 
1.67 
1.72 


0 

0 

0 

0 

0 

trace 

0 

0.45 

0.4S 

0 


Carbohy- 
drates 


Solu. 


6.93 

4.42 


.26 


0 

0 

3.12 

0 


-5.09- 


1.18 
3.25 
0.84 

2.71 


4.20 
2.73 
3.01 
0.58 


Insolu. 


0 
0 
0 
0 

1.1°, 

0 

0 

1.99 

1.22 


.41- 


0.20 
0.68 
0.10 
0.26 
0.11 
0.29 
0.47 
0.13 
0.34 


1  Leeds.    -E.E.Smith.    3  Minn.  Dairy  Rep.,  1896.    *  Chittenden.    SLeffman. 


As  .stated,  these  analyses  represent  the  constituent  percentages  as 
they  appear  in  the  nursing  bottle  ready  for  feeding.  The  condensed 
milk  is  attenuated  with  twelve  parts  of  water,  and  its  3.12  per  cent,  of 
soluble  carbohydrates  is  cane-sugar  added  as  preservative. 

Peptogenic  milk-powder  is  prepared  for  feeding  by  heating  the  pow- 
der in  a  given  quantity  of  milk,  cream,  and  water.  Mellin's  food. 
Imperial  Granum,  and  Eskay's  food,  all  require  the  addition  of  milk  or 


132  ARTIFICIAL    FEEDING 

milk  and  cream  for  use.  Milkine,  Nestle 's  food,  and  malted  milk  are 
prepared  with,  water  only. 

The  most  notable  feature  in  these  foods  is  the  paucity  of  fat,  which 
important  ingredient,  when  present,  is  ■  due  almost  entirely  to  the  added 
milk  or  cream.  Much  the  same  may  be  said  of  the  proteids  in  these 
foods,  with  perhaps  the  exception  of  milkine  and  malted  milk.  All 
are  low  in  lactose,  and  four  show  from  one  to  two  per  cent,  insoluble 
carbohydrates,  probably  starch.  Of  the  entire  group  nothing  appears 
which  is  necessarily  injurious  to  vigorous  digestive  organs.  The  excess 
of  cane-sugar  in  condensed  milk  is  frequently  criticised  as  favoring 
fermentation  if  its  use  be  long  continued. 

Applying  the  "  essentials"  (Chapter  X),  it  will  be  seen  that  no 
food,  as  presented  here,  fulfils  all  the  requirements  of  nutrition,  even 
if  well  borne.  It  is  easy  to  see  how  some  of  these  foods  might  prove 
very  valuable  by  the  addition  of  cream  or  milk-sugar,  or  both.  Thus 
milkine  and  malted  milk  would  be  improved  by  an  increase  of  fat. 
Nestle 's  food  shows  difficulties  in  adaptation  to  the  requirements  of  the 
infant  in  the  presence  of  insoluble  proteids  and  carbohydrates,  and  in 
the  low  percentage  of  essential  constituents. 

Six  things  are  to  be  kept  constantly  in  mind  in  substitute-  feeding : 

(1)  That  the  long-continued  use  of  food  deficient  in  fat  and  lecithin 
tends  to  the  production  of  malnutrition  and  rickets. 

(2)  Deficiency  in  soluble  proteids  retards  all  development.  It  is 
slow  starvation. 

(3)  The  use  of  cooked  foods  may  result  in  scorbutus,  hence  even 
sterilized  milk  should  not  be  administered  continuously. 

(4)  Food  which  would  not  meet  the  requirements  of  nutrition  for 
a  long-continued  period,  because  deficient  in  some  essential  constituent, 
may  be  used  temporarily,  as  in  travelling,  weaning,  or  temporary  removal 
from  the  breast. 

(5)  Gastric  digestion  must  be  developed  by  some  substance  which 
furnishes  soft  coagula,  for  which  purpose  nothing  is  known  to  equal 
milk. 

(6)  It  is  not  sufficient  merely  to  correct  dyspepsia;  the  infant  must 
he  nourished  and  show  a  gain  in  weight  and  strength. 


CHAPTER    XIII 
HYGIENE    OF    LATER    INFANCY 


CARE   OF    THE    MOUTH    AND    NASOPHARYNX 

At  the  beginning  of  the  second  year  the  average  child  shows  six 
teeth.  The  canines  should  have  been  cut  before  the  end  of  the  second 
year.  The  eruption  of  the  second  molars  terminates  first  dentition,  which 
should  be  completed  by  the  thirtieth  month.  Too  much  emphasis  cannot 
be  placed  upon  the  care  of  the  temporary  teeth.  Mechanical  injuries 
to  the  enamel,  also  necrosis,  should  be  guarded  against.  All  defects 
should  be  repaired  in  order  to  preserve  them  in  situ  until  complete 
absorption  of  the  roots  by  their  permanent  successors.  By  this  means, 
the  normal  conformation  of  the  maxillary  structures  is  secured  during 
the  rapid  facial  development.  Many  irregularities  of  the  permanent 
teeth  may  be  prevented  by  early  care  of  the  temporary.  Further, 
hygiene  of  the  mouth  is  demanded  because  the  decomposition  of  particles 
of  food  favors  development  of  toxins  and  accumulation  of  many  varieties 
of  bacteria. 

The  use  of  a  tooth-brush 
and  antiseptic  washes  should 
be  earnestly  insisted  upon.  Of 
equal  importance  is  the  care 
of  the  fauces,  nasal  passages, 
and  pharynx.  The  above-men- 
tioned areas,  from  the  bacterio- 


Fig.  70. — Nasal  or  ear  syringe. 


Fig.  71.— Oil  atomizer. 


pathological  stand-point,  are  ordinarily  the  most  filthy  cavities  of  the 

body.     Their  intimate  relation  to  the  three  vulnerable  tracts viz.,  the 

respiratory,  digestive,  and  auditory  systems— lends  special  significance 
to  the  demand  that  they  be  kept  the  freest  possible  from  infective  material 
or  germs.  During  infancy  and  childhood  the  toilet  of  the  mouth,  nose, 
and  nasopharynx  is  as  important  as  that  of  the  integument. 

It  is  easy  to  accustom  the  infant  to  inspection  and  cleansing  of  the 

133 


134  HYGIENE   OF  LATER  INFANCY 

mouth  and  nose,  if  begun  early — a  point  of  practical  value  aside  from 
prophylaxis,  when  later  such  inspection  and  treatment  become  necessary 
in  acute  pathologic  conditions.  The  latter,  however,  it  is  believed,  would 
rarely  be  necessary  if  the  former  were  strictly  observed.  The  child's 
toilet  outfit  is  incomplete  without  a  tooth-brush,  nasal  irrigator  (Fig.  70), 
and  an  atomizer  (Fig.  71). 

From  standing  by  the  chair,  the  infant  soon  acquires  independent 
locomotion,  so  that  the  second  year  is  fraught  with  danger  seldom  en- 
countered while  in  the  nurse's  arms, — such  as  liability  to  traumatism, 
undue  changes  of  temperature,  besides  infection  from  substances  intro- 
duced into  the  mouth,  the  common  receptacle  for  all  newly-found  articles. 
There  is  also  a  tendency  to  introduce  foreign  bodies  into  the  nasal  and 
aural  cavities,  and  trachea. 

"  Learning  to  walk  involves  a  whole  series  of  preliminary  accom- 
plishments, first  among  which  is  the  ability  to  hold  the  head  in  equilib- 
rium. This  is  usually  accomplished  about  the  fourth  month.  The  next 
stage  is  reached  a  month  or  two  later,  in  the  ability  to  sit  alone  upright. 


Fig.  72.— "  Orthopaedic"  shoe. 


The  soles  of  the  feet  are  frequently  turned  towards  each  other — a  partial 
reassumption  of  the  intrauterine  posture.  To  stand  alone  is  the  next 
stage,  and  anyone  who  has  watched  the  attempts  of  a  little  child  to  stand 
upright  and  walk,  will  be  convinced  that  he  is  moved  to  this  by  a  natural 
instinct.  Sometimes  a  child  who  has  learned  to  walk,  partially  or  wholly, 
reverts  for  a  season  to  creeping,  for  no  apparent  reason."     (Tracy.) 

Care  should  be  observed  that  children  be  not  encouraged  too  much 
in  this  new  accomplishment,  as  permanent  injury  to  ligaments  and  articu- 
lations with  deformity  may  result.  According  to  Dane,  the  arch  of 
the  foot  is  well  formed  at  birth,  and  generally  protected  by  a  pad  of 
fat,  which  has  led  to  an  erroneous  impression  of  flat  foot.      During 


Fig.  74.— Normal  development  of  infant  femur  and  tibia. 


Fig.  75. —Disturbed  alignment  from  wad  of  diaper :  production  of  bow-legs. 


CARE  OF  THE  FEET  AND  LEGS 


135 


the  first  two  years  the  arch  suffers  from  the  superincumbent  weight, 
more  particularly  in  heavy  babies.  With  increased  muscular  de- 
velopment, however,  the  recuperative  power  of  nature  tends  to  the 
correction  of  this  flattening,  so  that  by  the  fifth  year  the  arch  has 
resumed  its  normal  integrity.  Infants  instinctively  protect  themselves 
against  this  breaking  down  of  the  arch  by  turning  the  toes  in,  so  as 
to  bring  the  pressure  to  bear  more  upon  the  outer-  side  Efforts  on  the 
part  of  misguided  parents  to  compel  the  turning  out  of  the  toes  should 
be  discouraged.  The  shoes  usually  made  for  infants  are  a  good  illus- 
tration of  civilized  barbarity.  A  wide-toed  moccasin  of  flexible  material, 
allowing  free  expansion  to  the  foot,  made  rights  and  lefts,  is  recom- 
mended.    The  same  may  be  said  of  socks.    When  old  enough  to  walk  out 


Fig.  73.— "  Orthopaedic"  shoe. 


of  doors,  the  soles  may  be  further  protected  by  doubling  the  material, 
rather  than  by  the  use  of  stiff  soles  so  much  in  vogue.  Heeled  shoes 
were  never  intended  for  human  beings. 

The  relation  of  the  "  orthopaedic"  shoe  to  the  child's  foot  is  very 
well  shown  in  Figs.  72  and  73. 

The  natural  bow-legs  of  early  infancy  (Figs.  1,  3  and  4)  disappear 
in  the  third  year,  provided  proper  precaution  has  been  observed  against 
keeping  the  baby  on  his  feet  too  long. 

One  cause,  undoubtedly,  of  bow-legs  is  the  large  wadded  diaper 
which  acts  as  a  fulcrum  between  the  baby's  thighs,  when  the  legs  are 
bound  together  by  the  heavy  clothing.  This  tendency  to  curvature  of 
the  femora  and  the  disturbance  of  their  alignment  with  the  tibiae  are 
seen  in  the  skiagrams   (Figs.  74  and  75).     Figs.  76  and  77  also  show 


136  HYGIENE    OF    LATER    INFANCY 

the  effects  of  tight  diapers  in  their  constriction  of  the  pelvic  bones  during 
the  plastic  stage  of  infancy,  at  which  time  they  consist  of  many  centres 
of  ossification,  with  a  large  amount  of  cartilage. 

The  effects  of  tight  abdominal  bands  or  pinning  blankets  in  the  com- 
pression of  the  lower  thorax  is  also  shown  in  the  skiagram  (Fig.  78). 
These  errors  in  hygiene  are  too  obvious  to  need  further  comment. 

With  development  of  the  muscles,  the  rotundity  of  the  form  is  grad- 
ually lost  by  the  disappearance  of  subcutaneous  fat,  so  that  the  child 
appears  comparatively  slender. 

By  the  end  of  the  second  year  the  thoracic  circumference  exceeds 
that  of  the  head,  and  the  belly  is  less  prominent. 

The  fontanelle  has  closed  by  the  eighteenth  month,  and  the  frontal 
and  malar  eminences  begin  to  assert  themselves.  The  pulse-respiration 
ratio  gradually  establishes  itself  as  3:1,  the  respiration  giving  a  hint 
of  the  future  thoracic  type.     The  pulse  is  normally  about  100  to  115 


Fig.  76.— Pelvis  at  birth,  showing  cartilage. 

during  the  second  year,  with  the  respiration  25  to  35.  Both  are  subject 
to  disturbances  from  trivial  causes. 

The  kidneys  at  the  beginning  of  the  second  year  attain  their  greatest 
relative  weight. 

The  stomach  from  this  time  on  falls  behind  the  growth  ratio  of  the 
body.  In  fact,  the  same  may  be  said  of  all  the  viscera,  with  the  exception 
of  the  left  lung. 

The  eruption  of  the  teeth  has  long  been  recognized  as  a  suggestive 
indication  for  more  solid  forms  of  food.  The  changes  in  the  salivary, 
gastric,  and  pancreatic  secretions  bespeak  the  increasing  power  of  starch 
conversion  and  proteid  digestion.  The  process  of  mastication,  after  the 
advent  of  the  molars,  stimulates,  not  only  the  salivary  flow,  but  also  that 
of  the  lower  digestive  secretions,  which  suggest  the  permissibility  of  foods 
in  more  concentrated  form ;  so  that  it  is  not  unusual  to  find  farinaceous 
foods  well  borne  early  in  the  second  year.     In  modifications  of  milk, 


Fk;  77— Constriction  of  pelvis  by  tight  diaper.    Compare  with  Fig.  18,  skiagram  of  the  same  infant. 


Fig.  78.— Compression  of  abdomen  and  lower  thorax  by  tightbands.     Compare  with  skiagram  of  same 

subject  without  band  in  Fig.  17 


DIET    IN    LATER    INFANCY  137 

higher  percentages  of  proteids  are  required,  and  a  lower  percentage  of 
sugar  is  allowable,  since  this  ingredient  is  formed  from  the  starches. 
A  liberal  dietary  for  a  normal  infant,  twelve  to  fourteen  months  of  age, 
might  be  represented  by  the  following:  Breakfast,  6  a.m.,  carefully 
cooked  and  strained  oatmeal  three  and  one-half  ounces,  milk  four  ounces, 
and  cream  one-half  ounce ;  luncheon,  10  a.m.,  eight  to  ten  ounces  of  warm 
whole  milk ;  dinner,  2  p.m.,  mutton,  beef,  or  chicken  broth,  salted,  with 
zwieback  or  water-biscuit — as  much  as  he  will  take,  up  to  twelve  ounces ; 
supper,  6  p.m.,  a  cup  of  warm  milk  or  oatmeal  gruel ;  if  the  child  wakens 
at  night,  a  cup  of  milk  may  be  given.  Water  should  be  supplied  between 
times  ad  lib.,  but  not  immediately  preceding  a  meal.  As  the  second  year 
advances  the  quantities  of  proteids  and  starches  may  be  cautiously  in- 
creased. Not  infrequently  a  good  Liebig  food  may  be  used  to  advantage, 
enriched  with  cream.  The  need  for  fat  should  be  borne  in  mind ;  also 
that  the  food  should  contain  an  antiscorbutic — as  raw  meat  juice  ex- 
pressed from  lean  beef,  raw  egg  albumin  stirred  up  with  cool  water  and 
milk,  and  occasionally  orange  juice  or  a  well-baked  apple.  Toward  the 
close  of  the  year,  hard  water-cracker  or  zwieback  may  be  munched  as  an 
accompaniment  to  milk.  Stale  bread  or  toast  may  be  used  with  butter 
or  soft  poached  egg,  or  meat  gravies  from  the  table  roast.  The  following 
affords  ample  latitude  for  the  selection  of  an  appropriate  diet :  oatmeal 
with  its  high  percentage  of  fats  and  salts,  stewed  apples,  well-cooked 
rice,  thoroughly  baked  white  potato  with  butter  and  salt,  custards,  junket, 
gelatin  preparations,  sago,  cornstarch,  tapioca  well  cooked  and  served 
with  cream. 

Children  prone  to  constipation  should  have  ripe  bananas  rubbed 
through  a  sieve,  served  with  cream ;  also  the  juice  from  selected  stewed 
prunes.  Further  than  this,  fruits  are  not  advised  during  the  second 
year,  with  perhaps  the  exception  of  the  pulp  of  well-ripened,  seeded 
grapes.  Meat  fibre  is  not  advisable  during  this  period,  excepting  a  little 
scraped  beef  and  thoroughly  cooked  fish.  Sweetmeats  are  not  recom- 
mended, because  of  the  tendency  to  develop  a  distaste  for  the  more 
staple  articles  of  diet.  The  common  practice  of  taking  infants  to  the 
family  table  should  be  discouraged. 

It  would  seem  hardly  necessary  to  refer  again  to  the  necessity  for 
absolute  asepsis,  not  only  in  foods,  drinking  water,  and  dishes,  but  in 
every  detail  of  the  daily  care. 

The  infant  cannot  sleep  too  much.  He  should  sleep  from  fourteen  to 
sixteen  hours  out  of  the  twenty-four  during  the  second  year — protection 
from  noise,  strong  lights,  and  insects  being  necessary  to  secure  rest.  He 
will  rarely  go  to  sleep  unless  his  stomach  be  filled. 

An  infant's  nervous  system  is  in  so  unstable  a  condition  that  no  strain 
should  be  put  upon  its  faculties.  It  is  easy  to  see  that  by  seemingly  slight 
causes  it  may  be  injuriously  affected. 


CHAPTER   XIV 
PHYSIOLOGY    AND    HYGIENE    OF    CHILDHOOD 


NORMAL   PROPORTIONS 

By  the  end  of  the  third  year  the  child 's  head  and  face  may  serve  as 
an  index  of  normal  growth  and  development.  The  circumference  of  the 
head  should  measure  not  less  than  nineteen,  and  not  more  than  twenty- 
one  inches.  The  head  should  be  symmetrical  in  outline  and  free  from 
bossEe.  The  forehead  should  not  be  prominent  and  bulging  and  should 
be  free  from  ridges,  horizontal  or  vertical. 

The  eye  should  exhibit  no  incoordination  nor  errors  of  refraction  or 
accommodation. 

The  hearing  should  be  unimpaired  and  the  voice  clear  and  resonant. 
The  nostrils  should  be  ample  and  well  developed. 

The  teeth  should  be  symmetrical  in  their  arrangement  and  free  from 
erosions  and  defects.     The  roof  of  the  mouth  with  the  teeth  and  soft 


Fig.  79. — Saddle-shaped  palate.     (Talbot. ) 

palate  should  form  a  symmetrical  low  vault,  free  from  the  angles  seen 
in  Fig.  79. 

The  angles  of  the  maxilla  should  have  begun  to  assert  themselves, 
with  a  perceptible  broadening  of  the  lower  face. 

The  mastoid  processes  should  be  distinctly  outlined  and  the  ears 
normal  in  size  and  symmetrical  in  form. 

The  cervical,  dorsal,  and  lumbar  curvatures  in  the  spinal  column 
should  be  fully  established  and  there  should  be  no  lateral  deviations. 
138 


DIET    IN    CHILDHOOD  139 

The  circumference  of  the  chest  should  exceed  that  of  the  head  by 
about  one  inch. 

The  thorax  should  be  free  from  sulci  or  ridges,  the  sternum  flattened, 
and  the  ribs  free  from  headings.  Auseultation  should  give  respiratory 
sounds  audible  in  all  parts  of  the  lungs  and  puerile  in  character.  Abso- 
lute precordial  dulness  should  not  extend  to  the  right  of  the  midsternal 
line,  although  the  majority  of  observers  find  relative  dulness  to  the  right 
of  the  sternum  at  all  periods  of  childhood.  The  heart  rhythm  should 
be  trochaic  rather  than  iambic  in  metre,  as  expressive  of  the  relatively 
low  arterial  tension.  The  pulmonic  second  sound,  compared  with  the 
aortic,  is  accentuated  from  the  normally  higher  tension  on  that  side. 
Liver  dulness  may  extend  two  finger-breadths  below  the  right  anterior 
margin  of  the  ribs.  The  epigastric  depression  should  be  noticeable.  The 
umbilicus  should  be  slightly  above  the  centre  of  longitudinal  measure- 
ment. 

The  hips  should  be  perceptibly  broadened  and  the  limbs  symmetrical, 
showing  neither  bow-legs  nor  knock-knees. 

There  should  be  no  marked  disturbances  of  general  co-ordinated 
movements.  By  this  time  the  child's  vocabulary  may  embrace  about 
three  hundred  words,  including  some  indicating  color,  and  he  has  ac- 
quired the  use  of  the  first  personal  pronoun. 

The  above  enumeration  includes  a  few  of  the  phenomena  of  normal 
development,  from  which  the  degree  of  deviation  may  indicate  the 
extent  of  malnutrition,  used  in  the  broadest  sense. 

The  idea  of  protection  as  given  in  the  nursery  should  extend  through- 
out childhood,  with  such  modifications  as  the  changing  anatomy  and 
physiology  demand.  Although  he  may  have  acquired  a  considerable 
degree  of  digestive  strength,  as  compared  with  the  early  infancy,  still  he 
needs  watchful  care  over  food  and  environment.  In  regard  to  the  former, 
complete  nutrition  requires  the  five  principal  elements  (page  90)  in 
easily  digestible  form.  The  same  regularity  in  feeding  is  important, 
although  its  frequency  and  the  quantity,  as  well  as  the  material,  should 
vary  with  the  changing  requirements.  With  advancing  age  a  greater 
variety  in  articles  of  diet  is  advisable.  A  caution  is  necessary  on  account 
of  the  tendency  to  furnish  the  child  the  varied  dietary  of  the  adult,  too 
frequently  allowing  him  to  select  the  article  which  tickles  his  palate 
or  pleases  his  fancy.  No  error  would  be  greater,  as  the  palate  is  no 
guide  to  the  requirements  of  nutrition  and  malnutrition  is  invariably 
the  result.  A  child  regularly  fed  on  properly  selected  foods  will  rarely 
injure  himself  by  overeating.  The  use  of  condiments  (other  than  salt) 
and  flavors  to  tempt  the  appetite,  as  well  as  tea,  coffee,  and  stimulants, 
is  deprecated. 

Milk  should  hold  first  rank  among  the  leading  staples  throughout 
childhood.  Cultivation  of  the  appetite  for  milk,  too  often  neglected, 
proves  extremely  valuable,  when  in  sickness  it  is  necessary  to  restrict 
the  food  to  liquid.  It  may  be  mentioned,  as  a  hint  in  domestic  econ- 
omy, that  milk  is  one  of  the  cheapest  as  well  as  the  best  of  foods.     The 


140        PHYSIOLOGY   AND    HYGIENE    OF    CHILDHOOD 

tendency  to  decry  the  use  of  milk  as  an  alleged  source  of  tubercular 
infection  has  been  carried  further  than  later  pathological  findings  would 
warrant.  From  the  third  year  the  child  should  gradually  be  accus- 
tomed to  meat  as  a  source  of  proteid,  although  it  should  not  form  a 
part  of  more  than  one  meal  a  day,  until  after  the  sixth  year.  At  any 
time  it  should  represent  only  a  small  portion  of  the  entire  meal. 

Thorough  mastication  should  be  made  a  feature  of  the  child's  train- 
ing, and  he  should  not  be  allowed  to  "  wash  down"  imperfectly  masti- 
cated food.  From  the  end  of  the  third  year  fruits  should  be  given  at 
least  once  a  day.  Pastry,  even  though  not  positively  injurious,  tends  to 
pervert  the  appetite  and  leads  to  a  distaste  for  the  plain  essential  part 
of  the  dietary. 

Excretions  should  be  watched,  for  indications  for  changes  in  the  diet. 
Concentrated  highly  acid  urine  would  suggest  diminution  in  proteids, 
especially  meats,  with  increase  in  fluids,  vegetables,  and  fruits.  More 
particularly  do  lithgemic  children  with  tendency  to  eczema,  etc.,  need  to 
be  guarded  in  this  respect. 

Constipation  may  be  corrected  by  the  establishment  of  regularity  in 
evacuating  the  bowels,  preferably  in  the  morning  after  breakfast,  when 
the  ingestion  of  food  stimulates  intestinal  peristalsis.  Constipation  sug- 
gests the  addition  of  more  liquids  and  fruits.  Sometimes  it  may  be 
corrected  by  increasing  the  bulk  of  residue  by  coarser  breads  and 
vegetables. 

No  hard  and  fast  rules  can  be  made  in  regard  to  bathing.  The  tem- 
perature and  duration  of  the  bath  should  depend  upon  the  reactionary 
effects  upon  the  child.  The  wisdom  of  dragging  the  screaming  child  to 
the  cold  shower  bath  is  not  apparent  when  the  previous  admonitions 
concerning  shock  are  remembered.  Parents  may  err  in  the  too  frequent 
repetitions  of  the  bath.  General  bathing  should  never  follow  imme- 
diately the  ingestion  of  food. 

During  childhood  retiring  should  follow  soon  after  the  light  supper. 
Allowing  children  to  study,  read,  or  play  by  gas-light  is  not  conducive 
to  the  rest  and  recuperation  demanded  after  the  day's  fatigue. 

The  child  under  six  is  especially  fortunate  if  he  live  in  the  country, 
where  nature  furnishes  a  great  kindergarten  for  the  symmetrical  devel- 
opment of  all  his  faculties.  The  inherent  tendency  of  the  normal  child 
to  develop  himself  is  but  the  expression  of  the  organized  energy  of  per- 
fect nutrition.  His  pertinacious  instinct  for  investigation,  the  inherent 
curiosity  of  the  child,  furnishes  a  most  complete  training  of  brain  and 
muscles. 

The  kindergarten  of  the  city  is  but  a  makeshift,  called  into  existence 
by  the  artificial  environment  of  the  home.  The  very  fact  that  the  edu- 
cation of  the  child  in  kindergarten  and  school  is  under  control,  renders 
it  all  the  more  dangerous,  and  necessitates  the  exercise  of  the  finest 
judgment  and  broadest  knowledge  on  the  part  of  the  teacher.  If  this 
be  required  for  the  normally  developed  child,  how  much  greater  the 
necessity  in  the  various  abnormal  developments. 


EDUCATIOX  141 

"During  those  fits  of  rapid  growth  which  sometimes  occur  in  child- 
hood, the  great  abstraction  of  energy  is  shown  in  an  attendanl  prostra- 
tion, bodily  and  mental.  The  brain,  which  during  early  years  is  rela- 
tively large  in  mass  but  imperfect  in  structure,  will,  if  required  to 
perform  its  functions  with  undue  activity,  undergo  a  structural  advance 
greater  than  is  appropriate  to  its  age;  but  the  ultimate  effect  will  be  a 
falling  short  of  the  size  and  power  that  would  else  have  been  attained. 
Various  degrees  and  forms  of  bodily  derangement,  often  taking  years 
of  enforced  idleness  to  set  partially  right,  result  from  this  prolonged 
overexertion  of  the  mind.  Sometimes  the  heart  is  chiefly  affected. 
Sometimes  the  conspicuous  disorder  is  of  the  stomach.  In  many  cases 
both  heart  and  stomach  are  implicated.  The  sleep  is  often  short  and 
broken.  Excessive  study  is  a  terrible  mistake,  from  whatever  point  of 
view  regarded."     (Spencer.) 

This  epiotation  suggests  that  there  is  a  natural  course  of  development 
of  nerve  and  muscle  cells  evolved  from  exercise.  It  is  an  error  to  force 
the  exercise  of  function  too  early,  or  to  prolong  the  exercise  to  its 
impairment.  It  should  be  remembered  that  young  nerve  cells  tire  quickly, 
not  yet  having  the  stored  energy  of  maturity. 

The  earlier  education  is  naturally  restricted  to  the  grosser  movements 
of  the  free  limb  type.  During  this  stage  bf  development,  encouragement 
to  occupations  requiring  the  finer  co-ordinations  is  clearly  an  error,  which 
results  not  only  in  fatigue  of  the  cells  involved,  but  also  in  their  perma- 
nent impairment.  As  a  general  axiom  it  may  be  stated  that  permanent 
injury  surely  follows  prolonged  exercise  of  any  function,  physical  or 
mental,  out  of  its  order  in  the  sequence  of  natural  development.  With 
this  in  mind  young  children  will  not  be  urged  to  occupations  requiring 
refined  differentiations,  whether  in  the  use  of  the  needle,  pencil,  musical 
instrument,  or  in  the  study  of  numbers. 

The  artistic  products  of  the  kindergarten,  displayed  by  proud  parents 
and  teachers  as  evidences  of  progress  in  the  little  pupil's  training,  too 
often  suggest  the  fearful  cost  to  future  development  of  the  overstrained 
faculties  exercised  in  their  production.  That  the  children  enjoy  it  should 
have  no  more  weight  than  that  the  athlete  enjoys  the  victory  in  the 
contest  which  ruined  his  heart. 

As  shown  by  the  observations  of  Bowditch,  Gilbert,  Christopher, 
Porter,  Roberts,  and  Stephenson,  growth  is  not  represented  by  a  uniform 
rate ;  but  periods  are  observed  during  which  marked  increase  or  re- 
tardation in  the  rate  occurs.  In  fact,  in  one  organ  positive  loss  of  weight 
is  recorded,  as  in  the  brain,  which  at  thirteen  years  weighs  1465  grammes, 
but  at  fourteen  years  only  1300  grammes.  The  loss,  however,  is  more 
than  recovered  in  the  fifteenth  year,  when  the  average  weight  is  1500 
grammes.     ( Vierodt. ) 

The  heart  shows  a  decidedly  increased  area  of  dulness  after  the 
sixth  year.  The  great  increase  in  its  systolic  vigor,  however,  awaits  the 
remarkable  hypertrophy  of  pubescence.  Attention  is  called  to  a  pro- 
nounced deficiency  in  the  physical  vigor  of  children  from  seven  to  nine 


142        PHYSIOLOGY    AND    HYGIENE    OF    CHILDHOOD 

years  of  age,  which  is  termed  the  "period  of  fatigue."  This  is  mani- 
fested not  only  in  physical  but  also  in  mental  fatigue,  and  explains  the 
exhibition  of  many  nervous  symptoms  otherwise  unaccountable.  It 
would  appear  that  the  proverbial  laziness  of  this  age  has  its  foundation 
in  normal  physiologic  conditions. 

Krohn's  diagram  (Fig.  80)  shows  that  the  child  of  seven  fatigues 
less  readily  than  the  child  of  six,  but  that  the  child  of  eight  fatigues 
more  readily  than  the  child  of  either  six  or  seven.  The  child  of  nine 
has  a  fatigue  limit  about  equal  to  that  of  the  child  of  seven.  As  the 
years  advance,  the  readiness  of  fatigue  diminishes  materially  until  the 
period  of  puberty,  when  again  fatigue  more  readily  occurs  than  in  the 
years  immediately  preceding. 

Dr.  Gilbert,  in  his  examination  of  the  children  of  New  Haven,  found 
that  "girls  tire  more  easily  at  thirteen  than  at  twelve,  while  with  boys 
the  variance  comes  a  year  later,  from  thirteen  to  fourteen.     In  close 


Krohn's  diagram,  showing  fatigue  periods. 


connection  with  this  is  the  growth  in  weight.  Boys  increase  18.3  pounds 
between  fourteen  and  fifteen  years,  and  17  pounds  between  fifteen  and 
sixteen,  but  between  sixteen  and  seventeen  years  the  increase  is  only 
3  pounds." 

The  most  rapid  growth  of  girls  ceases  at  thirteen,  while  at  fourteen 
rapid  growth  of  boys  is  just  beginning.  At  about  this  age  the  girl 
reaches  her  maximum  brain  weight,  just  at  the  time  that  the  boy's  brain 
loses  considerable  weight,  due  to  the  large  amount  of  blood  being  with- 
drawn from  the  brain  to  nourish  viscera  during  their  rapid  revolutional 
changes  at  this  period.  Krohn  states  that  at  the  onset  of  pubescence 
individual  characteristics  and  idiosyncrasies  are  intensified.  Further- 
more, the  greatest  of  the  hereditary  qualities  come  out  and  the  most 
dangerous  of  hereditary  defects  manifest  themselves.     It  is  at  this  time 


CAPACITY    FOR    ATTENTION  143 

that  nervous  diseases,  especially  in  higher  centres,  and  also  mental 
peculiarities,  make  their  first  real  appearance. 

From  the  foregoing,  the  conclusion  is  obvious  that  in  the  allotment 
of  tasks  in  the  arbitrary  routine  of  exercises  styled  educational,  the  bin- 
dens  must  be  distributed  with  due  reference  to  these  physiologic  periods 
of  development.  To  expect  the  same  degree  of  progress  during  the 
fatigue  period  as  may  be  secured  in  the  preceding  or  subsequent  years, 
would  result  not  only  in  disappointment  to  parents,  but  also  in  perma- 
nent mental  and  physical  injury  to  the  child.  At  about  eight  years 
dilated  ventricle  with  its  mitral  insufficiency  is  a  familiar  picture  in 
pediatric  clinics.  The  unstable  equilibrium  characteristic  of  pubescence, 
also,  should  be  a  warning  of  diminished  capacity  for  prolonged  effort. 

The  researches  of  Edwin  Chadwick  furnish  statistics  which  are  of 
interest  as  indicating  the  limit  of  mental  concentration  at  different 
periods  of  growth.  Thus  he  finds  that  fifteen  minutes  is  the  limit  of 
time  that  children  of  from  five  to  seven  years  can  concentrate  attention 
upon  one  subject.  That  twenty  minutes'  attention  is  all  that  may  be 
expected  of  children  from  seven  to  ten  years,  twenty-five  minutes  for 
those  between  ten  and  twelve,  and  that  pupils  from  twelve  to  eighteen 
rarely  exceed  thirty  minutes.  It  is  seen  from  the  foregoing  that  the 
capacity  for  sustained  attention,  in  point  of  duration,  is  below  the 
usually  accepted  belief  as  illustrated  by  the  recitation  schedules  of  our 
schools.  The  exhaustion  of  the  power  of  attention  renders  every  subse- 
quent moment  spent  in  the  school-room  worse  than  futile,  from  an  edu- 
cational stand-point.  This  is  particularly  true  because  the  habit  of 
inattention  thus  engendered  is  so  fatal  to  educational  progress. 

The  capacity  for  attention  may  be  reduced  below  the  normal  by 
attending  circumstances,  so  that,  in  certain  cases,  exhaustion  speedily 
follows  apparently  reasonable  school-room  demands.  Instances  of  this 
kind  are  not  infrequently  due  to  inferior  nutrition  from  inadequate 
home  hygiene,  or  a  child  may  be  worked  beyond  the  capacity  of  his 
strength  from  mistaken  notions  of  economy  on  the  part  of  the  parents. 

It  has  been  repeatedly  demonstrated  that  eye-strain  is  a  prolific  cause 
of  early  exhaustion  of  nerve  force  in  school  children,  and  that  want 
of  the  application  of  the  principles  of  optics  is  constantly  laying 
the  foundation  for  a  great  variety  of  pathological  processes  which 
handicap  the  future  and  shorten  lives.  Much  good  has  been  accom- 
plished where  attention  has  been  given  to  better  lighting,  seating  accord- 
ing to  powers  of  visual  distances,  substitution  of  the  clear  tablet  for  the 
indistinct  slate,  improved  size  and  forms  of  type  in  text-books,  shorter 
hours  of  study,  systematic  testing  of  visual  power  and  the  application 
of  corrective  lenses  or  cylinders  when  needed. 

Somewhat  analogous  to  the  preceding  are  the  effects  upon  the  child 
of  car-strain,  whether  due  to  defects  in  the  organ  of  hearing,  to  imper- 
fect acoustic  arrangement  of  the  room,  or  to  indistinct  enunciation  of  the 
teacher.  A  little  observation  will  show  that  apparent  dulness  in  the 
pupil  is  frequently  the  result  of  imperfect  hearing,  or  of  exhaustion 


144        PHYSIOLOGY   AND    HYGIENE    OF    CHILDHOOD 

from  the  undue  effort  to  grasp  the  meaning  of  sentences  but  partially 
comprehended.  Hence  tests  of  hearing  should  be  applied  with  a  view 
to  correction. 

The  tests  of  physical  endurance  inaugurated  by  Gilbert,  in  New 
Haven,  and  Christopher,  in  Chicago,  bid  fair  to  establish  a  standard 
for  the  amount  of  work  to  which  pupils  of  different  ages  may  be  ration- 
ally assigned. 

Muscular  fatigue  from  constrained  positions,  as  evidenced  by  rest- 
lessness of  pupils  so  familiar  to  every  teacher,  has  received  much  atten- 
tion, so  that  the  instructor  may  well  be  considered  negligent  who  does 
not  vary  the  monotony  of  study  and  recitations  with  frequent  brief 
exercises  in  physical  culture. 

It  would  hardly  appear  necessary  to  mention  the  absolute  need  of 
fresh  air  and  deep  inspiration,  so  long  has  physiology  demonstrated  the 
true  function  of  respiration.  Still,  the  school-room  visitor  often  finds 
the  need  of  much  improvement  in  this  direction.  In  proof  of  this  may 
be  cited  the  contrast  in  the  attitude  and  facial  expression  of  pupils 
immediately  preceding  and  following  the  recess. 

Vicious  attitudes,  resulting  in  permanent  physical  deformities,  are 
too  often  caused  by  improper  school  furniture  or  its  arrangement  with 
reference  to  the  light.  The  desk  too  high  or  too  low,  the  relation  of 
feet  to  floor,  and  the  want  of  support  to  the  spinal  column,  particularly 
to  the  dorsolumbar  region,  too  frequently  show  their  baleful  effects  in 
spinal  curvature,  with  hip  or  shoulder  deformities. 

In  regard  to  the  length  of  sessions,  and  study  out  of  school  hours, 
there  can  be  no  difference  of  opinion.  In  the  lower  grades  especially 
nothing  is  gained,  though  much  may  be  lost,  by  requiring  pupils  to  study 
their  tasks  at  home.  Overwork,  if  insisted  upon,  will  give  inferior  results 
and  that,  too.  at  the  expense  of  the  impairment  of  the  newly  developing 
functions,  far-reaching  in  consequences. 

The  subject  of  child  labor,  both  from  the  humane  and  economic  stand- 
point, has  received  so  much  attention  in  recent  years  that  mere  mention 
of  the  conclusions  must  suffice.  By  those  who  have  thoughtfully  studied 
this  question  the  unwisdom  of  employing  children  during  prolonged 
periods  has  been  demonstrated  in  various  ways.  Eeference  to  preceding 
pages  will  show  some  reasons  why  children,  during  the  process  of  devel- 
opment, are  incapable  of  continued  effort  requiring  manual  dexterity, 
even  of  the  simplest  type. 

The  limited  store  of  energy  at  this  stage  allows  early  exhaustion  of 
the  nerve  cells,  with  impairment  of  co-ordination.  Thus  it  has  been  shown 
that  accidents  due  to  clumsy  or  awkward  motions  occur  with  significant 
frequency  in  the  latter  part  of  the  day.  The  laws  restricting  child 
labor  are  not  only  humane  and  protective  to  a  class  who  rightly  should 
be  protected,  but  also  to  the  State,  which  in  many  instances  must  become 
responsible  for  the  crippled. 


CHAPTER  XV 
HYGIENE  OF  THE  PREMATURE  INFANT 

CONDITIONS  OF  PREMATURITY 

It  is  only  in  recent  years  that  the  subject  of  the  care  of  the  prema- 
turely born  has  engaged  the  attention  of  the  profession.  Formerly  it 
was  the  accepted  belief  that  the  majority  of  infants  born  four  to  eight 
weeks  before  term  were  insufficiently  developed  to  survive.  In  fact, 
this  opinion  was  the  logical  outgrowth  of  the  high  rate  of  mortality  at 
this  age.  The  exception  to  the  rule  was  seen  in  an  occasional  survival, 
evidently  the  result  of  unusual  care  in  management  or  exceptional  vigor 
of  the  infant. 

The  picture  presented  by  the  infant  after  seven  months  of  intra- 
uterine gestation  is  certainly  not  encouraging,  and  it  is  not  strange  that 
it  was  often  laid  away  as  unworthy  of  any  effort  at  preservation.  The 
respiration  is  shallow,  irregular,  frequently  suspended  for  long  inter- 
vals, and  coming  at  times  in  gasps.  The  breath  is  sometimes  cold,  as 
of  one  dying  from  exsanguination.  The  heart's  action  is  reduced  at 
times  to  an  almost  imperceptible  flutter,  no  wave  being  apparent  in  the 
arteries.  The  absence  of  subcutaneous  fat  (a  deposition  of  the  later 
weeks  of  gestation)  gives  the  appearance  of  extreme  emaciation,  the 
feeble  muscles  showing  like  strings  under  the  thin  integument. 

The  skin  is  soft  and  of  a  raw  red  color.  The  nails  are  short,  not 
extending  to  the  ends  of  the  fingers,  and  the  integument  of  the  dorsal 
surfaces  is  covered  with  lanugo.  The  eyes  are  sealed  with  a  gummy 
secretion,  the  hair  extends  low  on  the  forehead  and  the  bones  of  the 
head  are  widely  separated  and  very  compressible  in  their  membranes. 
In  girls  the  labia  minora  project  beyond  the  majora. 

The  temperature  is  usually  subnormal,  as  heat  production  is  defec- 
tive. This  defect  is  due  in  part  to  the  imperfect  manner  in  which  respi- 
ration is  carried  on.  The  anterior  portions  of  the  lungs  only  are  ex- 
panded, the  posterior  remaining  atelectatic  for  many  days.  It  is  easy 
to  understand  why  premature  infants  are  prone  to  suffer  from  hernia. 

These  conditions,  with  the  feeble  wail  or  even  absence  of  cry,  and 
the  almost  motionless  limbs,  present  a  contrast  to  the  normal  infant 
which  may  afford  some  excuse  for  the  lack  of  attention  previously 
afforded  this  class  (Fig.  81). 

The  temperature  of  the  obstetrical  chamber  in  premature  delivery 
should  not  be  under  91°  F.  (33°  C),  and  at  birth  the  child  should  be 
immediately  wrapped  in  warmed  blankets.  The  rule  of  not  ligating  the 
cord  until  pulsation  has  ceased  is  especially  important.     If  artificial 

10  145 


146 


HYGIENE    OP    THE    PREMATURE    INFANT 


respiration  be  necessary,  it  is  not  wise  to  use  the  vigorous  methods  of 
Sylvester  or  Schultze,  or  to  expose  the  infant  to  the  shock  of  immersion 
in  cold  water.     (See  Asphyxia). 

The  idea  of  the  incubator,  or  couveuse,  wherever  originated,  was 
brought  to  the  attention  of  the  public  by  Crede  and  Tarnier,  who  re- 
ported great  saving  of  life  by  this  means,  the  former  having  a  mortality 
of  but  eighteen  per  cent,  and  the  latter  of  thirty-three  per  cent.  How- 
ever, Crede  would  not  accept  infants  who  weighed  less  than  five  and 


Fig.  81.— Infant  ten  weeks  premature ;  weight  at  birth,  3%  pounds ;  weight  at  two  weeks,  2%  pounds ; 

weight  at  eight  weeks,  8  pounds. 


one-half  pounds,  while  the  limit  placed  by  Tarnier  was  four  pounds. 
The  reports  of  these  observers  established  the  fact  that  lack  of  full 
development  at  birth  was  not  necessarily  an  obstacle  to  survival  and 
growth.  The  incubator,  whether  of  the  simple  primitive  type  employed 
in  the  Leipzig  Maternity  by  Crede,  or  the  intricate,  complicated,  device 
of  the  present  day,  has  for  its  purpose  the  fulfilment  of  such  hygienic 
principles  as  avoidance  of  shock,  maintenance  of  warmth,  and  the  supply 
of  pure  air  (Fig.  82). 

In  the  couveuse  a  temperature  of  from  88°  to  98°  F.  (31°-37°  C.) 


IXCUJATOR 


147 


is  maintained  by  hot  water,  which  may  be  introduced  between  the 
double  walls  of  the  apparatus  through  coils  of  pipe,  or  by  flasks  of  hot 
water  placed  in  the  false  bottom.  The  nude  infant  rests  in  the  upper 
portion  upon  soft  wool,  is  covered  with  the  same,  and  light  is  excluded 
by  an  opaque  lid.  Air  is  supplied  through  an  opening  in  the  bottom, 
escaping  through  another  at  the  top.  The  more  elaborate  apparatus 
includes  a  thermometer,  a  gas-jet  for  maintaining  heat,  a  thermostat 
for  its  regulation,  mechanism  for  regulating  air-supply,  and  scales  for 
weighing.  In  the  absence  of  the  couveuse,  most  excellent  results  may 
be  secured  by  the  exercise  of  a  little  ingenuity  with  a  padded  clothes- 
basket,  hot-water  bottles,  a  pound  of  wool  and  a  blanket.  This  is  sug- 
gested because  of  the  extreme  importance  of  the  immediate  application 
of  these  principles,  as  even  a  temporary  delay  may  allow  a  reduction 
of  temperature  that  will  endanger  life. 


Fig.  82.— Incubator. 


As  close  an  approximation  as  possible  to  the  conditions  existing  be- 
fore delivery  is  the  object  sought.  To  this  condition  air  and  food  must 
be  added.  The  former  should  be  pure,  warm,  and  moist.  The  food  must 
be  of  the  character  and  administered  in  quantities  best  adapted  to  the 
immature  digestive  tract.  These  infants  should  not  be  required  to  wait 
until  lactation  is  established,  but  should  be  fed  within  a  few  hours  after 
birth. 

Milk-sugar  solution  is  well  borne  and  furnishes  heat.  Fats  are 
absorbed  in  smaller  quantity  and  proteids  are  tolerated  in  extremely 
reduced  percentages.  A  generous  supply  of  water  should  be  given.  It 
has  been  suggested  that  the  urine  be  watched  for  uric  acid  as  an  indica- 
tion for  the  reduction  of  proteids  in  the  food.  For  the  purpose  of  nutri- 
tion and  to  prevent  desiccation,  daily  oiling  should  be  practised  when 
not  found  irritating  to  the  skin. 

The  disturbance  incident  to  suckling,  and  the  usual  inability  to  nurse 
from   muscular   weakness,    render   breast    feeding   impracticable.      The 


148 


HYGIENE    OF    THE    PREMATURE    INFANT 


breasts  should  be  pumped  regularly  and  the  milk,  diluted  with  an  equal 
part  of  4  per  cent,  milk-sugar  solution,  may  be  given  by  a  spoon  or 
feeding-tube,  preferably  the  latter,  until  the  infant  has  gained  sufficient 
strength  to  use  the  nipple.  This  tube  is  so  constructed  that  compression 
of  the  bulb  forces  the  fluid  through  the  small  nipple  into  the  infant 's 
mouth  (Fig.  83).  Small  quantities,  sometimes  not  exceeding  a  gramme, 
should  be  given  hourly,  keeping  in  mind  that  errors  are  usually  on  the 
side  of  overfeeding.  Failure  to  observe  this  point 
may  induce  regurgitation  of  food,  or  even  death  from 
embarrassed  heart  action.  In  some  cases  gavage  may 
be  required,  or  nasal  feeding  may  be  preferred. 

It  is  generally  accepted  that  the  size  and  vigor  of 
a  full-term  infant  bear  a  direct  ratio  to  the  chances 
for  rate  of  growth  and  survival.  This  is  not  less  true 
when  applied  to  premature  infants.  Some  babies  at 
full  term  are  born  to  die,  notwithstanding  the  best  of 
attention,  the  full  forty  weeks  of  gestation  failing  to 
provide  sufficient  vigor  for  the  maintenance  of  their 
vital  functions.  It  is  hardly  reasonable  to  suppose 
that  their  chances  would  have  been  improyed  by  pre- 
mature delivery. 

Reference  has  been  made  in  a  preceding  chapter 
to  the  burden  imposed  upon  the  heart  at  birth,  as  seen 
in  its  uncertain,  irregular  action.  It  is  not  surprising 
that,  at  this  earlier  stage  of  development,  the  heart 
should  be  less  well  prepared  to  assume  the  burden  of 
systemic  circulation.  In  fact,  there  is  imminent  danger  of  syncope  from 
the  slightest  disturbance.  To  guard  against  this  the  horizontal  position 
must  be  maintained  and  all  rough  and  unnecessary  manipulations 
avoided,  reducing  the  work  of  the  heart  to  the  minimum  of  physiological 
requirements.  It  may  be  even  necessary  to  administer  alcoholic  stimu- 
lation in  appropriate  doses.  The  continued  use  of  brandy  with  the  food 
at  this  time  has  the  sanction  of  the  highest  authorities. 

As  to  the  respiration  and  pulse,  no  definite  ratio  has  been  recorded. 
It  is  seen  that  the  management  of  the  premature  infant  requires  constant 
watchfulness  and  extreme  care  as  to  details.  By  regular  weighing  and 
by  watching  the  discharges,  evidence  is  obtained  as  to  his  condition,  which 
may  serve  as  a  guide  for  the  amount  and  character  of  the  food. 

It  is  not  unusual,  when  nutrition  is  well  established,  to  find  the  tem- 
perature of  the  premature  ranging  higher  than  that  of  the  full-term 
infant,  which  would  seem  analogous  to  his  incompleted  intrauterine 
existence  when  growth  and  development  are  seen  at  their  highest. 

If  evidences  of  satisfactory  progress  appear  in  continuous  gain,  im- 
proved respiration,  steadier  heart  action,  undisturbed  digestion,  accom- 
panied by  rotundity  of  figure  and  livelier  movements,  a  cautious  reduc- 
tion of  temperature  may  be  attempted  and  the  infant  may  be  gradually 
accustomed  to  the  light  and  environment  of  the  new-born  at  full  term. 


Fig.  83.— Feeding-tube. 


CHAPTER    XVI 
CONGENITAL    MALFORMATIONS 

CAPUT   SUCCEDANEUM 

So  common  as  to  rank  as  a  physiological  phenomenon  is  the  forma- 
tion during  delivery  of  a  diffuse,  boggy  tumor,  known  as  caput  suc- 
cedaneum.  It  varies  in  size  with  the  duration  of  labor,  and  in  position 
with  the  presentation.  In  the  common  left  occipitoanterior  presentation 
the  tumor  is  found  on  the  right  parietal,  extending  over  the  posterior 
fontanelle  and  occipital  bone.  It  consists  of  a  serous  infiltration  of  the 
scalp  in  that  portion  freed  from  pressure  by  the  dilating  os  uteri.  Com- 
pression of  the  scalp  between  the  skull  and  bony  inlet  temporarily  checks 
return  circulation  and  causes  the  oedema.  Often  the  overlying  skin  is 
bruised,  and  if  the  labor  be  severe  the  tumor  may  be  purplish  in  color, 
although  a  considerable  hemorrhage  is  rare.  If  there  should  be  delay 
at  the  outlet  a  secondary  tumor  may  form  which  is  usually  in  the  median 
line. 

The  fluid  is  absorbed  in  from  two  to  four  days  and  no  treatment  is 
required. 

CEPHALHEMATOMA. 

Cephalhematoma,  as  its  name  suggests,  is  caused  by  an  extravasation 
of  blood  between  the  cranial  bones  and  their  investments.  Different 
varieties  are  recognized,  due  to  different  locations  of  the  effused  blood, 
as  subaponeurotic,  subperiosteal,  subdural,  or  subarachnoid.  Thus,  it 
is  seen  that  the  tumor  may  be  due  to  an  extravasation  purely  external 
to  the  skull,  or  the  blood  may  be  connected  with  an  accumulation  within 
the  cranium. 

As  stated  in  the  chapter  on  Anatomy,  from  the  close  attachment  of 
the  pericranium  to  the  dura  at  the  sutures,  a  cephalhematoma  must  be 
limited  in  its  area  by  the  borders  of  the  bone  over  which  it  occurs. 
Hence,  it  need  never  be  mistaken  for  a  hernia  cerebri,  which  protrudes 
at  an  aperture  or  unprotected  area.  The  apparent  crater-like  opening 
beneath  the  cephalhamiatoma,  with  the  feeling  of  crepitation  at  its  periph- 
ery, is  due  to  the  rapid  deposition  of  bony  material  at  the  margin  of 
periosteal  separation,  where  the  osteoblasts  are  still  actively  at  work. 

From  a  caput  succedaneum  it  may  be  easily  distinguished  by  the 
frequent  extension  beyond  sutures  and  fontanelles,  discoloration  of  skin, 
pitting  on  pressure  and  early  disappearance  of  the  latter. 

The  restricted  hemorrhage  is  presumably  due  to  pressure  upon  un- 
usually fragile  blood-vessels  under  peculiar  hamiic  conditions.  It  is 
almost  invariably  found  in  the  children  of  poorly  nourished  mothers. 

140 


150  CONGENITAL    MALFORMATIONS 

It  is  not  necessarily  due  to  pressure  during  passage  through  the  birth- 
canal,  since  cases  are  recorded  of  cephalhgematoma  in  infants  delivered 
by  Caesarian  section.  Breech  presentations  also  occasionally  show  this 
lesion,  and  instances  are  not  wanting  in  which  the  tumor  has  been  found 
on  the  head  of  the  prematurely  born. 

The  prognosis  is  usually  favorable,  in  the  absence  of  symptoms  indica- 
tive of  extensive  intracranial  extravasations. 

A  mild  astringent  placebo  may  be  used  as  a  prevention' to  surgical 
interference,  absorption  usually  occurring  in  from  two  to  ten  weeks. 

MENINGOCELE,   ENCEPHALOCELE,    HYDRENCEPHALOCELE. 

The  protrusion  of  a  portion  of  the  membranes  of  the  brain  through 
an  opening  in  the  skull,  due  to  deficient  ossification,  is  known  as  a 
meningocele.  If  there  is  also  brain  substance  situated  in  the  protru- 
sion it  forms  encephalocele,  or  hernia  cerebri.    This  is  the  most  frequent 


Fig.  84.— Anencephalus,  acrania.     (Rush  Medical  Museum.) 

type.  A  marked  degree  of  encephalocele,  in  which  the  greater  part  of 
the  brain  is  outside  the  cranium,  resting  in  a  membranous  sac  and  drag- 
ging the  head  backward,  is  termed  exencephalus  (Fig.  14).  A  still 
greater  degree  of  arrest  of  development  is  the  entire  absence  of  brain- 
tissue,  anencephalus.  This  is  usually  associated  with  absence  of  all  the 
bones  of  the  skull,  excepting  those  at  the  base, — acrania  (Fig.  84).  If, 
in  addition  to  the  brain  and  its  coverings,  the  tumor  contain  cerebro- 
spinal fluid  continuous  with  the  ventricles,  it  is  called  hydr encephalo- 
cele. 

The  protrusion  may  vary  in  size  from  a  small  nut  to  that  of  the 
infant's  head.    It  is  usually  translucent  and  pulsating,  increasing  with 


HERNIA    CEREBRI  151 

screaming.    The  tumor  is  in  most  instances  reducible,  but  the  reduction 

may  cause  symptoms  of  compression, — opisthotonos,  convulsions,  or 
coma.  The  covering  is  thin,  but  not  as  defective  as  is  frequently  the  case 
in  spina  bifida.  Other  deformities  are  often  present.  Although  present 
at  birth,  these  tumors  are  apt  to  increase  rapidly,  followed  by  evidences 
of  meningeal  irritation,  convulsions,  and  paralysis. 

The  most  frequent  site  is  in  the  occipital  region,  in  the  spaces  between 
the  centres  of  ossification  of  the  occipital  bone  (Figs.  11  and  12),  the 
posterior  fontanelle,  or  the  foramen  magnum.  Next  in  frequency  the 
tumor  is  seen  at  the  root  of  the  nose,  a  little  to  one  side  of  the  median 
line,  arising  from  the  junction  of  the  frontal  and  nasal  bones.  They 
have  also  been  found  in  the  mouth  and  pharynx. 

The  only  explanation  offered  for  the  occurrence  of  these  hernias  is 
an  intrauterine  hydrocephalus  and  defective  ossification. 

From  cephalhamiatomata  they  may  be  differentiated  by  their  loca- 
tion, pulsation,  reducibility,  and  sharp,  bony  boundaries. 

Infants,  the  subject  of  anencephalus,  acrania,  and  exencephalus  sur- 
vive birth  only  a  few  days.  The  majority  of  cases  showing  lesser  degrees 
succumb  in  the  early  months  of  life  from  rupture,  meningitis,  or  con- 
vulsions. In  a  few  rare  cases  a  spontaneous  decrease  in  size  with  recovery 
has  occurred. 

Tapping  is  of  temporary  benefit  only.  The  injection  of  iodine  and 
glycerin  has  been  followed  in  some  cases  by  shrinkage  of  the  tumor. 
Clamping  of  the  pedicle,  excision,  and  other  surgical  procedures,  have 
been  successful  in  removing  the  protrusion,  but  the  infants  almost  inva- 
riably have  developed  convulsions,  hydrocephalus,  and  idiocy. 

CONGENITAL    HYDROCEPHALUS. 

Hydrocephalus  is  of  congenital  origin  in  the  large  proportion  of 
cases.  The  accumulation  of  fluid  within  the  cranium  may  be  so  great 
as  to  make  delivery  of  the  head  impossible  without  aspiration.  Much 
more  frequently  the  head  at  birth  is  only  slightly  in  excess  of  the  normal 
size  (34  to  36  Cm.)  (133/5-142/s  inches),  but  increases  more  or  less 
rapidly.  The  fluid  usually  distends  the  lateral  ventricles,  less  often  the 
fourth  ventricle,  and  may  be  found  between  the  meninges  (external 
hydrocephalus). 

The  etiology  is  still  unknown.  Trauma  to  the  mother  during  gesta- 
tion, alcoholism,  tuberculosis,  and  syphilis,  in  one  or  both  parents,  have 
been  advanced  as  causes  by  various  observers.  A  family  predisposition 
is  recognized,  two  or  more  cases  (in  one  instance  seven)  in  the  same 
family  being  reported.  The  cause  of  the  accumulation  of  fluid  in  the 
ventricles  may  not  be  the  same  in  all  patients.  There  may  be  a  local 
meningitis  closing  the  foramen  of  Magendie,  some  lesion  of  the  cho- 
rioid  plexuses  causing  an  excess  of  secretion,  a  syphilitic  leptomeningitis 
and  endarteritis,  or  some  obstruction  to  circulation,  such  as  a  brain 
tumor. 

As  stated,  the  large  size  of  the  head  may  not  attract  attention  until 


152  CONGENITAL    MALFORMATIONS 

the  infant  is  two  or  three  weeks,  or  as  many  months  old.  Sometimes  the 
increase  is  rapid,  averaging  a  centimetre  a  week.  When  advanced  the 
fontanelles  are  large  and  bulging;  the 'bones  forming  the  vault  become 
thin  and  widely  separated;  the  skin  covering  them  seems  stretched  and 
shiny,  with  distended  veins;  and  the  hair  is  scanty  and  dry.  The  face 
and  body  are  relatively  small,  yet  they  may  be  of  average  size  for  an 
infant  of  that  age.  The  prominent  eyes  are  directed  downwards,  and 
are  not  fully  covered  by  the  lids.  Occasionally  nystagmus  and  stra- 
bismus are  present.  The  child  is  unable  to  support  the  head,  which 
rolls  around  helplessly.  Other  malformations  are  frequently  associated. 
Convulsions  and  spastic  paralyses  are  common.  The  brain  always  suf- 
fers to  some  extent,  although  if  the  pressure  develop  slowly  the  amount 
of  impairment  may  be  surprisingly  little.  The  optic  nerves,  from  stretch- 
ing and  pressure,  may  atrophy,  but  the  other  cranial  nerves  are  rarely 
affected.  The  brain  substance  may  be  thinned  to  a  few  millimetres  in 
thickness,  with  little  distinction  between  the  gray  and  white  matter. 

In  slight  degrees  of  hydrocephalus  it  may  be  difficult  to  differentiate 
from  the  large  head  of  rhachitis.  In  the  latter  disease,  however,  the 
general  shape  of  the  vault  is  square  rather  than  globular,  the  fontanelles 
are  not  always  bulging,  and  there  may  be  other  signs, — as  rosary  or 
enlarged  epiphyses.  Repeated  careful  measurements  of  the  cranium 
will  show  if  the  enlargement  be  progressive. 

Death  quickly  follows  birth  in  marked  cases.  In  a  few  instances 
recently  reported,  spontaneous  evacuation  has  occurred  through  fissures 
at  the  base  of  the  skull  into  the  nostrils,  followed  by  improvement  and 
apparent  recovery.  The  usual  course  is  increasing  weakness,  imbecility, 
and  death  from  some  intercurrent  disease  in  the  first  five  years  of  life. 

Aspiration  alone  or  with  drainage  may  temporarily  relieve  symptoms 
of  pressure,  but  this  is  usually  the  extent  of  benefit  from  surgery.  Lum- 
bar puncture  may  be  as  effective  if  the  channel  of  communication  be 
open.  Compression  by  plaster  or  elastic  bandage  is  advocated  by  some, 
but  is  open  to  the  objections  of  interfering  with  circulation  and  in- 
creasing the  pressure  on  the  brain.  The  possibility  of  the  presence  of 
hereditary  syphilis  makes  the  use  of  potassium  iodide  and  mercury 
worthy  of  trial  in  all  cases.    The  other  treatment  must  be  symptomatic. 

MICROCEPHALUS. 

The  term  microcephalus  is  restricted  by  some  to  heads  that  measure 
less  than  40.5  or  43  Cm.  (16  or  17  inches)  in  children  over  one  year. 
The  more  liberal  definition  of  the  word  includes  all  those  in  whom  the 
circumference  of  the  head  is  much  below  the  average  for  age,  or  greatly 
disproportionate  to  the  body. 

The  theory  that  the  condition  arises  from  a  premature  ossification 
of  the  bones  of  the  cranium  is  not  now  generally  accepted  as  true  in 
all  cases.  Microcephaly  is  probably  due,  in  most  instances,  to  inflamma- 
tion or  other  diseases  of  the  fetal  brain. 

Usually  the  anterior  portion  of  the  skull  and  brain  are  most  affected. 


SPINA    BIFIDA 


153 


The  forehead  is  narrow  and  low.  Varying  degrees  of  iodicy,  as  well  as 
imperfect  control  of  the  Limbs,  are  present. 

Although  the  lack  of  development  may  be  much  more  evidenl  in  sunn- 
parts,  the  mass  of  the  brain  is  lighter  than  the  average,  and  the  fissures 
and  convolutions  are  shallow.  There  is  frequently  an  increase  of  fluid 
in  the  ventricles. 

Craniectomy,  consisting  in  the  removal  of  a  longitudinal  strip  of 
bone  on  one  or  both  sides,  parallel  with  the  sagittal  suture,  was  advocated 
a  few  years  ago.  The  results  of  the  operation  were  not  favorable  enough 
to  justify  its  practice. 


MALFORMATIONS    OF    THE    SPINAL    CORD. 

Very  rare  deformities  of  the  spinal  cord-  are,  its  entire  absence, 
amyelia,  a  reduction  in  size,  atclomyelia,  or  a  division  in  halves,  diplo- 
myelia.  In  amyelia,  nerve  tissue  may  be  replaced  by  a  solid  cord  of 
connective  tissue  or  one  containing  fluid  in  a  central  canal.  This  mal- 
formation is  often  associated  with  anencephalus  and  is   incompatible 

with  life.  Syringomyelia  is  due  to  con- 
genital imperfection  of  the  spinal  cord, 
which  only  needs  some  trauma  in  post- 
natal life,  to  act  as  an  exciting  cause.  It 
is  of  interest  to  note  that  the  gray  sub- 
stance of  the  cord  shows  a  lack  of  sym- 
metrical development  in  cases  of  intra- 
uterine amputation  of  a  member. 

The  most  common  and  clinically  im- 
portant congenital  malformation  of  the 
cord  is  spina  bifida.  This  consists  of  a 
bony  defect  in  the  vertebral  column,  with 
protrusion  of  the  cord  or  its  membranes. 
It  is  seen  as  an  elastic,  more  or  less  trans- 
lucent tumor,  varying  in  size  from  a  hazel- 
nut to  a  cocoanut,  or  even  larger  (Fig. 
85). 

.  It  is  stated  that  in  a  few  instances  the 
lamina3  are  not  the  defective  parts,  but 
the  hernia  protrudes  through  the  bodies 
of  the  vertebra3,  presenting  in  the  thorax 
or  abdomen.  It  may  also  insinuate  its 
way  through  an  intervertebral  notch. 

Pressure  on  the  tumor  will  reduce  its  size,  but  in  nearly  all  cases 
there  follow  evidences  of  cerebral  pressure,  seen  in  greater  tension  of 
the  fontanel le,  changes  in  pulse  and  respiration,  restlessness  or  convul- 
sions. With  the  reduction,  it  may  be  possible  to  palpate  the  edges  of 
the  bony  clefts.  Imperfect  development  in  other  parts  of  the  body  is 
commonly  seen  in  these  patients. 

Probably  the  nonunion  of  the  vertebral  arches  is  secondary  to  an 


FIG.  85.— Spina  bifida. 


154  CONGENITAL    MALFORMATIONS 

increased  pressure  from  an  inflammation  of  the  cord  or  its  meninges  in 
embryonic  life. 

The  three  varieties  of  spina  bifida  correspond  to  those  of  hydro- 
cephalus. In  the  first  the  tumor  consists  simply  of  membranes  and  fluid, 
— meningocele  spinalis.  It  is  sometimes  found  in  the  cervical  region, 
may  be  pedunculated,  and  is  usually  covered  with  integument  which  may 
be  normal  or  the  seat  of  a  nasvus.  This  form  may  be  attended  by  no 
symptoms  and  offers  the  most  favorable  prognosis. 

The  second  variety,  meningomyelocele,  is  the  most  common,  forming 
over  sixty  per  cent,  of  all. cases.  It  is  usually  located  in  the  lumbo- 
sacral region,  is  sessile  and  contains  nerve  tissue  as  well  as  meninges. 
The  cord  and  nerves  spread  over  the  inner  surface  of  the  sac,  or  a 
median  dimple  may  mark  the  attachment  of  the  cord  to  one  point.  Often 
there  is  an  overgrowth  of  coarse  hair  surrounding  the  sac.  Not  only  is 
there  defect  of  bone  but  also  of  muscle  and  skin,  so  that  the  hernia  has 
for  a  covering  only  the  very  thin,  bluish-red  meninges. 

In  the  third  variety  there  is  a  dilatation  of  the  spinal  canal,  a  cystic 
tumor,  which  also  protrudes  through  the  vertebral  cleft.  This  is  the 
form  most  often  associated  with  hydrocephalus. 

In  the  second  and  third  varieties  there  is  always  some  degeneration 
of  the  cord,  cauda  equina,  or  the  nerves,  due  to  pressure.  This  results 
in  paraplegia,  talipes,  incontinence  of  urine  and  fasces,  and  frequently 
in  bed-sores  or  other  trophic  lesions. 

From  imperfect  covering,  rupture  of  the  hernia  may  occur  at  birth, 
but  if  not  then  it  is  very  apt  to  result  later.  The  usual  course  is  gradual 
increase  in  size,  and  death  from  marasmus,  convulsions,  or  septic  men- 
ingitis after  rupture.  Either  with  or  without  operation  these  children 
do  not  often  survive  the  second  year  of  life.  Very  rarely  instances  of 
spontaneous  cure  are  recorded. 

The  treatment  is  surgical.  Unless  rupture  be  imminent,  many  sur- 
geons postpone  operation  until  the  fourth  or  fifth  month  of  age,  protect- 
ing the  sac  from  pressure  by  a  rubber  ring  and  from  infection  by  clean- 
liness. Aspiration  and  the  injection  of  iodine  and  glycerin  is  thought 
by  some  to  offer  as  favorable  results  as  any  method,  but  this  is  not 
devoid  of  danger.  Convulsions  and  death  have  followed  in  a  few  hours 
in  several  cases.  The  more  radical  operation  of  dissection,  return  of 
nerve  tissues  to  spinal  canal,  and  careful  suturing  of  opening,  is  quite 
as  likely  to  be  followed  by  hydrocephalus  as  are  other  methods. 

CONGENITAL  DEFORMITIES   OF  EXTREMITIES. 

The  congenital  deformities  of  the  extremities  are  almost  as  numerous 
as  the  articulations.  In  any  one  of  these,  growth  may  be  inhibited  or 
perverted  by  prolonged  pressure  in  utero.  Deformities  may  result,  also, 
from  constrictions  from  amniotic  bands  or  loops  of  the  umbilical  cord. 
Not  infrequently  intrauterine  amputations  result  from  this  cause  (Figs. 
86  and  87). 

Of  not  uncommon  occurrence  is  congenital  dislocation  of  the  hip, 


DEFORMITIES    OF    EXTREMITIES 


1 55 


which  may  be  either  uni-  or  bilateral  (Pigs.  88,  89,  and  90).  Although 
occasionally  hip  dislocation  may  be  regarded  as  ail  accident  of  labor,  a 
large  majority  of  cases  result  from  causes  that  operate  during  gesta- 
tion. Among  those  assigned  arc  external  trauma  during  gestation, 
uterine  contractions  acting  upon  the  femur  as  a  lever,  effusion  into  the 
joint  cavity,  malformation  of  the  acetabulum  or  femoral  head,  and 
affections  of  the  central  nervous  system  of  the  child. 

The  most  common  form  of  dis- 
location is  upwards  and  backwards. 
The  thigh  may  form  any  angle  with 
the  axis  of  the  body,  up  to  90°. 

A  not  rare  location  of  congeni- 
tal deformity  is  the  ankle  and  foot, 
which  may  exhibit  all  degrees  from 
a  slight  subluxation,  with  relaxed 
ligaments,  to  extreme  talipes  or 
club-foot  (Fig.  91.) 


- 


Fig.  86.— Amputation  by  strangulation  of  foetal 
cord.    (From  cast  in  Warren  Muoeum.) 


Fig.  87.— Double  congenital  dislocation  of    hip. 
Girl,  aged  31.,  years. 


Deformities  of  this  class  should  be  promptly  referred  to  the  ortho- 
paedic surgeon,  as  much  depends  upon  their  early  treatment. 


MALFORMATIONS    OF    THE    EYE. 

So  complex  is  its  mechanism,  it  is  not  strange  that  the  eye  should 
be  the  seat  of  various  congenital  defects.  The  following  are  some  of  the 
most  common : 


156 


CONGENITAL    MALFORMATIONS 


Anophthalmos  is  the  condition  in  which  there  is  absence  or  mere 
rudiments  of  the  eyeball.  In  microphthalmos  (a  partial  arrest  of  de- 
velopment) there  is  more  or  less  blindness  according  to  degree  of  defect. 
There  may  be  ankyloblepharon,  in  which  adherence  of  the  eyelids,  nor- 
mal to  fetal  life,  persists  or  is  due  to  an  intrauterine  conjunctivitis.  A 
family  predisposition  to  congenital  cataract  is  sometimes  seen,  extend- 
ing through  several  generations.  It  is  usually  associated  with  other  de- 
fects of  the  eye,  hence  some  degree  of  amblyopia  is  common. 

A  cleft  in  the  eyelids,  iris,  or  chorioid  is  termed  colomba.  Colomba 
iridis  is  usually  found  in  the  lower  half,  and  may  vary  from  a  mere 
line  to  a  quadrant. 

Congenital  ptosis,  not  attributable  to  pressure  of  forceps  or  other 


Fig.  SS.— Congenital  malformations  of  fingers  due  to  constricting  amniotic  bands. 


known  cause,  is  occasionally  seen.  As  the  child  gains  control  of  muscular 
action,  the  drooping  lessens,  but  probably  never  entirely  disappears. 

In  Epicanthus  there  is  a  crescentric  fold  of  skin  at  the  inner  canthus, 
sometimes  extending  as  far  outward  as  the  cornea.  This  peculiarity 
is  sometimes  transmitted  for  three  or  more  generations. 

The  outer  angle  of  the  eye  is  a  not  uncommon  site  for  Dermoid  cysts, 
having  the  usual  varied  contents.  If  growth  is  rapid  in  one  of  these 
cysts,  immediate  extirpation  is  advisable. 

In  Albinism  there  is  a  congenital  deficiency  of  pigmentation  of  iris 
and  chorioid,  as  well  as  of  the  skin  and  hair.    The  pupil  often  looks  pink 


CLEFT    PALATE  157 

because  the  fundi  are  lighted  through  the  sclerotics,  and  nystagmus  is 
common.    With  growth  there  is  usually  a  slight  increase  in  pigmentation. 

MALFORMATIONS    OP    THE   EAR. 

In  the  development  of  the  ear,  in  the  second  and  third  months  of 
fetal  life,  bits  of  cartilage  are  in  some  way  detached  from  the  original 
mass,  or  fail  to  unite,  and  form  supernumerary  auricles  or  auricular 
appendages.  These  are  sometimes  seen  as  smooth,  wart-like  projec- 
tions, sessile  or  pedunculated,  located  more  frequently  in  front  of 
the  ear.  They  may  vary  in  size  from  a  pinhead  to  a  walnut,  and  may 
be  the  only/  anomaly  present.  The  pedunculated  forms  are  easily 
removed. 

Various  deformities  of  the  external  ear  are  frequently  seen  and, 
because  sometimes  associated  with  imperfect  development  of  the  brain 
as  well  as  other  parts  of  the  body,  are  classed  by  some  writers  as  stig- 
mata of  degeneration. 

The  auricles  at  birth  are  often  folded  forward  and  in  many  cases  may 
remain  outstanding,  unless  persistent  efforts  are  made  to  press  them 
back  in  place.  Strips  of  adhesive  plaster  are  sufficient  for  retention  in 
new-born  infants.  In  older  children  it  may  be  necessary  to  excise  a 
portion  of  the  skin  and  cartilage  from  the  posterior  surface  of  the  ear 
and  suture  to  the  skin  over  the  mastoid  process. 

A  more  serious  defect  is  congenital  atresia  of  the  external  auditory 
canal.  This  is  often  associated  with  malformation  of  the  auricle  or 
with  its  entire  absence.  The  labyrinth  may  be  normal  and  bone  con- 
duction good.  The  operation  for  the  formation  of  an  artificial  canal  has 
not  been  permanently  successful.  Whatever  the  explanation  may  be,  it 
is  of  interest  that  suppurative  otitis  media  or  mastoiditis  has  never  been 
reported  in  these  cases. 

H/EMATOMA   OF    STERNOMASTOID — CAPUT   OBSTIPUM. 

Occasionally  there  is  noted,  a  week  or  two  after  birth,  a  swelling  in 
the  sternomastoid  muscle,  usually  of  the  right  side.  This  tumor  is 
in  the  sheath  of  the  muscle,  in  its  middle  or  upper  portion,  and  by  many 
observers  is  believed  to  be  due  to  trauma  during  labor,  causing  rupture 
of  blood-vessels  and  muscle-fibres,  and  later  a  myositis.  The  large  major- 
ity of  these  cases  occur  during  breech  presentation,  and  traction  on  the 
neck  is  thought  to  be  a  cause.  In  a  smaller  percentage  forceps  have 
been  used.  The  lack  of  tone  present  in  deep  asphyxia  probably  favors 
the  escape  of  blood.  Hamiatomata  have  also  been  recorded  in  normal 
labors  and  an  intrauterine  origin  is  claimed  by  some  writers. 

The  tumor  seems  tender  to  pressure  and  the  infant  cries  on  sudden 
motion  involving  the  sternomastoid. 

Its  usual  course  is  towards  recovery  without  deformity,  although 
wry-neck  sometimes  results.  Nothing  in  the  way  of  treatment  is  needed 
beyond  careful  support  of  the  head  at  all  times. 


loo  CONGENITAL    MALFORMATIONS 

CLEFT    PALATE HARELIP. 

Cleft  palate  is  simply  an  imperfect  closure  of  the  fetal  gap  in  this 
region.  It  is  in  the  median  line  and  often  involves  the  soft  palate  and 
uvula.  If  the  cleft  in  the  hard  palate  include  the  alveolar  border  it 
leaves  the  median  line  and  follows  the  suture  between  the  maxillary 
proper  and  the  os  incivisum.  This  defect  is  usually  associated  with  a 
corresponding  fissure  in  the  upper  lip  (harelip),  which  rarely,  if  ever, 
occurs  in  the  median  line  (Figs.  92  to  95). 

The  defect  may  interfere  with  nursing  and  occasionally  with  deglu- 
tition, while  the  catarrh,  frequently  associated  with  this  malformation, 
favors  infection.  Modern  surgery  affords  great  relief  for  cleft  palate, 
hence  all  eases  should  be  referred  early  to  the  specialist.  If  neglected, 
speech  defects  result  which  are  difficult  of  correction.  Like  many 
other  congenital  defects,  the  condition  is  usually  accompanied  by 
lowered  nutrition  and  feeble  resistance,  a  fact  to  be  remembered  in 
prognosis. 

BRANCHIAL   FISTULA. 

Certain  congenital  fistula?  are  sometimes  found  within  the  neck, 
which  are  due  to  the  partial  persistence  of  one  of  the  branchial  clefts. 
In  the  foetus  these  clefts  occur  between  the  branchial  arches,  which  are 
five  in  number  (Fig.  15).  When  present  at  birth  these  fistula?  appear 
as  very  fine  canals  opening  into  minute  orifices  in  one  or  both  sides  of 
the  anterior  surface  of  the  neck,  leading  backwards  and  upwards 
towards  the  pharynx  or  oesophagus.  The  length  may  be  from  five  to 
ten  millimetres  and  the  diameter  from  that  of  a  bristle  to  an  ordinary 
probe.  They  usually  exist  about  the  line  of  the  third  or  fourth  cleft, 
and  are  often  found  just  above  the  sternoclavicular  joint.  Certain 
polycystic,  congenital  tumors,  occurring  as  hydrocele  of  the  neck,  may 
be  developed  from  imperfectly  closed  clefts. 

The  treatment  is  surgical. 

FACIAL    DEFECTS. 

A  failure  in  union  of  the  branchial  clefts  may  result  in  a  large  median 
opening,  extending  from  the  inferior  maxilla?  to  orbits.  A  minor  degree 
of  malformation,  more  frequently  seen,  is  macrostoma,  in  which  the  cleft 
extends  from  the  angles  of  the  lips  towards  or  to  the  ears  on  one  or  both 
sides.  Fissures  or  fistula?  are  occasionally  found  at  the  outer  angles  of 
the  eyes,  ala?  nasi,  or  in  the  lower  lip. 

MALFORMATION  OF  THE  DIGESTIVE  TRACT. 

Very  rarely  there  is  atresia,  more  or  less  complete,  of  the  mouth  at 
birth,  requiring  immediate  operation. 

(Tongue-Tie  and  Macroglossia  are  discussed  in  Part  II.) 
Of  interest,  only  as  a  peculiarity,  is  the  bifurcation  of  the  uvula. 
More  serious  is  the  persistence  of  a  septum  at  the  upper  end  of  the 
oesophagus  occluding  the  mouth  at  the  pillars  of  the  fauces.     Other 


Fig.  89.— Same  as  Fig.  88,  side  view. 


Fig.  90.— Dislocation  of  hip.     (Rush  Medical  Museum.)  Fig.  91.— Congenital  club  foot.     I  Dr.  W.  Blanchard.) 


Fig.  92— Double  cleft  palate  with  harelip. 
(  Brophy.) 


Fig.  93.— Side  view  of  Fig.  92. 


Flo.  9-4.—  Single  cleft  palate  with  harelip. 


Fifi.  9.").— Same  after  operation  for  closure  of 
palate.     (Brophy.) 


MALFORMATIONS    OF    THE    DIGESTIVE    TRACT        159 

malformations  of  the  oesophagus  are  occlusion  at  any  portion,  bifurca- 
tion of  its  upper  end,  absence  of  partition  between  it  and  the  trachea, 
and  fistulous  communication  with  the  external  surface. 

The  most  common  defect  of  the  stomach  is  a  congenital  stricture  of 
the  pylorus,  which  is  described  in  Part  II.  From  either  imperfect 
development  or  a  fetal  peritonitis,  any  part  of  the  intestines  may  be 
occluded,  the  most  frequent  sites,  besides  the  pylorus,  being  at  the 
orifice  of  the  common  bile  duct,  Meckel's  diverticulum,  and  the  ileum. 
The  lesion  may  be  a  stricture,  or  the  intestine  may  be  represented  merely 
by  a  cord  of  fibrous  tissue  of  several  centimetres'  length.  The  symp- 
toms are  persistent  vomiting,  absence  of  stools,  rapid  emaciation,  and 
early  death.  The  omphalo-mesenteric  duct  may  persist  (Meckel's  diver- 
ticulum, Fig.  96)  and  remain  patent  throughout  its  extent,  forming  a 
fecal  fistula.  It  may  protrude  as  a  tumor  at  the  umbilicus,  or,  by  shut- 
ting in  a  loop  of  intestine,  may  cause  strangulation. 


Fig.  96 — Meckel's  diverticulum. 

Atresia  ani  of  mild  degree  consists  simply  in  a  failure  of  invagina- 
tion of  the  skin  while  the  rectum  is  normal  in  location  (Fig.  97).  In 
the  second  form  the  rectum  has  been  arrested  in  development  or  diverted 
from  its  course,  the  anal  portion  having  been  fully  formed,  but  ending 
in  a  blind  pouch  (Fig.  98).  In  the  least  favorable  class  both  anus  and 
rectum  are  defective  in  development  and  may  be  several  centimetres 
apart  (Fig.  99).  If  the  imperforation  is  located  high  up  in  the  rectum 
the  diagnosis  is  recognized  by  the  absence  of  stools,  distended  abdomen, 
and  unhealthy  tint  of  the  skin.  Operative  measures  in  the  first  class  are 
simple  and  successful.  In  the  second  and  third  they  are  much  more 
difficult  and  it  may  be  necessary  in  either  instance  to  form  an  artificial 
anus. 

Other  malformations  of  the  rectum  are  its  abnormal  termination  in 
the  bladder,  urethra,  vagina,  or  perineum  (Fig.  100).  In  these  cases 
the  treatment  is  surgical,  but  immediate  operation  is  not  so  urgent  as 
in  the  forms  of  atresia. 


160  CONGENITAL    MALFORMATIONS 

CONGENITAL   DILATATION    OF    THE    COLON   AND    STOMACH. 

Several  cases  of  enormous  dilatation  of  the  colon,  existing  since  birth, 
have  been  recorded.  The  walls  of  the  large  intestines  are  usually  hyper- 
trophied  and  present  many  ulcerated  areas.  These  ulcers  are  probably 
due  to  irritation  and  infection  from  retained  faeces.  In  some  cases  the 
dilatation  has  been  caused  by  stricture  or  occlusion  of  some  portion  of 
the  sigmoid  or  rectum  from  maldevelopment  or  fetal  peritonitis.  In 
others,  which  have  been  termed  idiopathic,  it  has  been  impossible  to 
ascribe  a  cause. 

The  symptoms  are  obstinate  constipation,  followed  by  varying  inter- 
vals of  diarrhoea,  abdominal  distention  which  entirely  disappears  after 
evacuation  of  the  bowels,  and  progressive  emaciation. 

Medical  treatment  has  been  of  little  benefit.  The  only  hope  of  relief 
is  in  surgery,  either  by  excision  of  a  portion  of  the  redundancy  or  entire 
ablation  of  the  colon,  forming  an  artificial  anus  or  joining  the  small 
intestine  to  the  rectum. 

The  stomach  is  occasionally  found  enormously  distended  at  birth, 
without  evidence  of  pyloric  stenosis  (Fig.  101). 

UMBILICAL  DEFECTS. 

An  abnormality  that  rarely  occurs  is  a  congenital  hernia  in  the 
cord,  which  must  be  distinguished  from  the  umbilical  hernia  developed 
after  birth.  In  the  congenital  form,  a  portion  of  the  intestine  or  liver 
may  work  its  way  in  among  the  structures  of  the  cord  and  receive  its 
coverings  from  them.  There  are  a  few  cases  reported  of  the  intestine 
being  included  in  the  accoucheur's  ligature. 

In  the  foetus  the  intestinal  canal  is  cut  off  from  the  yolk-sac  by  the 
gradual  growth  of  the  ventral  plates  and  their  ultimate  union  in  the 
middle  line.  This  union  occurs  latest  at  the  umbilicus.  In  some  cases 
of  imperfect  development  the  anterior  wall  is  more  or  less  entirely 
absent,  and  the  viscera  are  either  entirely  uncovered  or  protected  only 
by  amnion  and  parietal  peritoneum.  This  condition,  congenital  exom- 
phalos,  is  usually  associated  with  other  deformities  which  are  inconsistent 
with  any  but  very  brief  existence  (Fig.  102).  Reposition  of  the  viscera 
and  closure  of  the  cleft  have  been  successful  in  a  few  instances. 

From  the  mode  of  development  it  is  easy  to  see  how  a  congenital 
fistula  at  the  umbilicus  may  result  from  persistent  patency  of  the 
urachus.  If  there  be  no  obstruction  to  the  discharge  of  urine  through 
the  urethra,  touching  the  opening  of  the  sinus  with  the  solid  nitrate 
of  silver  is  usually  sufficient.  If  the  urine  continues  to  discharge  at 
the  umbilicus,  it  will  be  necessary  to  freshen  the  surface  of  the  fistula 
and  close  with  sutures. 

DIASTASIS   OF    THE   RECTI    MUSCLES. 

Diastasis  is  due  to  a  defective  union  of  the  abdominal  walls  in  the 
median  line.    The  marked  cases  have  occurred  in  rhachitic  children.    In 


Fig.  97.— Atresia  ani.     (Keating. 


Fig.  98. — Rectal  occlusion.     ( Keating. ) 


Fig.  99. — Absence  of  rectum. 


Fk..  Inn.— Common  cloaca. 


^\  '      v^e" 


w 


Dilated  ■    \ 

c  ■  \        ' 


Mf 


aid, 


S 


tt 


Fig.  101.— Dissection  of  new-born,  dilated  stomach  displacing  liver.     (Dr.  J.  D.  Merrill.) 


Fig.  102.— Exomphalos  including  a  portion  of  the  liver  and  loop  of  intestine. 


DIASTASIS  161 

them  the  lowered  muscular  tone  of  the  stomach  and  intestines  has  resulted 
in  fermentation  and  tympanites,  with  increased  pressure  against  walls 
that  are  congenitally  weak  and  also  poorly  nourished.  The  separation 
may  be  slight  or  equal  the  width  of  three  fingers.  It  is  seen  in  the  upper 
portion  of  the  abdomen,  extending  from  the  point  of  the  sternum  to  the 
umbilicus.  If  of  slight  degree  it  may  be  brought  out  by  causing  the 
patient  to  raise  the  head  and  shoulders  from  the  bed.  Bringing  the 
edges  together  by  adhesive  plaster  or  bandage,  with  attention  to  diges- 
tive disturbances,  is  usually  sufficient  treatment. 

Congenital  inguinal  hernia  includes  not  only  those  cases  in  which 
the  rupture  is  actually  present  at  birth,  but  also  those  which  develop 
in  the  early  weeks  and  months  of  extrauterine  life.  It  has  been  stated 
that  the  funicular  process  is  patent  in  fifty-nine  per  cent,  of  all  infants 
at  birth.  Distention  of  the  abdomen  from  flatulent  indigestion,  or  strain- 
ing due  to  a  phimosis  or  coughing,  are  probably  the  chief  factors  that 
determine  the  presence  of  a  rupture. 

Boys  are  much  more  frequently  subject  to  inguinal  hernia  than  girls, 
and  in  a  large  proportion  of  cases  the  right  side  is  the  one  involved, 
owing  to  the  earlier  closure  of  the  process  on  the  left  side. 

The  symptoms  are  the  same  as  in  adults  and  the  diagnosis  is  made 
by  the  same  methods.  Enlarged  lymphatic  glands,  hydrocele,  and  fatty 
tumors  are  to  be  excluded  by  the  consistency,  translucence,  "and  reduci- 
bility  of  the  swelling. 

The  prognosis  is  far  more  favorable  in  early  life  than  later.  Many 
small  hernias  in  young  infants  doubtless  recover  spontaneously,  owing 
to  the  natural  tendency  to  closure  of  the  peritoneal  pouch.  This  ten- 
dency should  be  favored  by  care  in  feeding  so  that  abdominal  pressure 
be  not  increased  by  flatulence,  or  it  may  be  that  circumcision  should 
be  the  first  step  in  the  treatment.  In  nearly  all  cases  under  four  years, 
the  trial  of  a  truss  should  be  made  before  resorting  to  surgery.  The 
exceptions  to  this  are  hernias  that  are  increasing  in  size,  complicated  by 
hydrocele  strangulated,  or  those  that  cannot  conveniently  receive  proper 
care. 

In  young  babies  the  wool  truss  usually  gives  satisfactory  results  and 
has  the  advantage  of  small  cost.  A  skein  of  wool  is  passed  under  the 
body  at  the  waist  line.  One  end  is  passed  through  the  other  at  a  point 
corresponding  with  the  external  abdominal  ring,  then  carried  between 
the  thighs  and  fastened  behind  to  the  portion  encircling  the  waist.  As 
to  the  length  of  time  the  truss  should  be  worn,  the  rule  has  been  given 
that  if  begun  before  the  age  of  one  year,  it  should  not  be  discarded 
before  the  third  year ;  if  not  worn  before  the  age  of  three,  it  should  be 
kept  on  until  the  age  of  seven. 

In  cases  requiring  operation  the  prognosis  is  good,  even  in  very 
young  infants.  Kecovery  has  followed  the  operation  for  double  inguinal 
hernia  in  an  infant  twenty-four  hours  old. 

Femoral  hernias  are  extremely  rare,  even  in  girls.  The  prospect 
of  cure  by  a  truss  is  much  smaller  in  this  form.  , 

11 


162 


CONGENITAL    MALFORMATIONS 


DIAPHRAGMATIC    HERNIA. 

Occasionally  there  are  reported  cases  of  diaphragmatic  hernia.  In 
these  there  is  a  congenital  deficiency  of  a  portion  of  the  diaphragm  (the 
left  anterior  border  has  been  the  part  affected  in  nearly  all  the  cases), 
allowing  the  escape  of  a  less  or  greater  portion  of  the  abdominal  viscera 
into  the  thorax.  The  heart  is  crowded  to  the  right  and  the  development 
of  the  left  lung  is  interfered  with.  The  grouping  of  symptoms  produced 
are  often  puzzling,  and  in  most  instances  the  condition  has  been  dis- 
covered for  the  first  time  at  the  autopsy.  Naturally  the  prognosis  is 
unfavorable. 

Congenital  Heart  Disease  is  discussed  in  Part  II. 

EXSTROPHY  OF   THE  BLADDER — ECTOPIA  VESICiE. 

One  of  the  most  remarkable  deformities  is  exstrophy  of  the  bladder 
(Fig.  103).    Here,  not  only  is  there  deficiency  of  the  abdominal  wall  but 


Fig.  103.— Exstrophy  of  the  bladder.    1,  Umbilical  cicatrix ;  2,  bladder  wall ;  3,  rudimentary  penis; 

4,  scrotum ;  5,  inguinal  hernia. 


also  of  part  of  the  genito-urinary  apparatus.  In  complete  cases  of  ex- 
troversion there  is  absence  of  the  umbilicus  and  of  the  anterior  wall 
below  it.  There  is  no  symphysis, — a  gap  existing  between  the  pubes; 
there  is  absence  of  the  anterior  wall  of  the  bladder,  of  the  greater  part 
of  the  penis,  and  of  the  roof  of  the  urethra.  The  scrotum  is  also  bifid 
and  the  testicles  are  usually  undescended. 

The  urine  escapes  constantly  from  the  openings  of  the  ureters,  caus- 
ing irritation  of  the  skin  and  an  ammoniacal  odor.  The  unprotected 
bladder  wall  becomes  irritated  from  the  friction  of  the  clothing. 

Deflecting  the  ureters  into  the  rectum  has  been  successful  in  a 
few  cases,  but  in  others  it  has  been  followed  by  an  ascending  pyelo- 
nephritis. Plastic  operations  are  usually  deferred  until  the  third  or 
fourth  year. 

For  cryptorchidism,  see  Undescended  Testicles,  Part  II. 


.WE  VI  163 

CONGENITAL    ATRESIA    OP    URETHRA,    VULVA    AND    VAGINA. 

Anuria  in  the  new-born  may  be  due  to  an  imperforate  urethra.  The 
obstruction  is  usually  merely  a  thin  layer  of  membrane  which  is  easily 
punctured  by  the  probe.  Congenital  contraction  of  the  meatus  or  strict- 
ure of  any  portion  of  the  urethra  is  sometimes  present  causing  slow 
micturition,  retention,  and  resultant  cystitis.  Cohesion  of  the  inner 
surfaces  of  the  labia  minora  occasionally  require  separation,  which  is 
usually  accomplished  without  difficulty. 

There  is  occasionally  seen  an  abnormality  resulting  from  the  non- 
absorption  of  the  septum  formed  by  the  infolding  at  the  cloaca.  This 
results  in  an  imperforate  hymen. 

Atresia  of  the  vagina  is  frequently  not  discovered  until  puberty.  If 
the  condition  be  recognized,  incision  of  the  imperforate  hymen  or  septum 
of  the  vagina  should  be  made  during  later  infancy,  as  the  membrane 
is  then  thinner  and  less  vascular  than  later  in  life. 

Pliimosis  (see  Part  II). 

EPISPADIAS — HYPOSPADIAS. 

Sometimes  the  inferior  wall  of  the  urethra  and  corresponding  part 
of  the  corpus  spongiosum  are  wanting,  as  in  hypospadias ;  or  there  may 
be  a  deficiency  in  the  superior  wall  of  the  canal  and  adjacent  parts  of 
the  corpora  cavernosa,  as  in  epispadias.  The  last-named  condition  is 
much  rarer  than  hypospadias.  In  both  forms  of  malformation  there 
is  deficient  power  of  retention  of  urine  and  consequent  intertrigo,  cystitis, 
and  erosion.  Plastic  operations  are  indicated,  but  are  not  always  suc- 
cessful, as  fistulous  openings  are  apt  to  persist. 

N^VI — BIRTH    MARKS;     PORT- WINE    STAINS. 

The  skin  of  the  face  is  very  thin  and  exceedingly  vascular,  hence 
it  is  often  the  seat  of  nawi.  These  are  of  two  forms,  pigmented  and 
vascular.  A  pigmented  naevus  having  a  smooth  surface  is  known  as 
ncevus  spilus;  if  warty  and  uneven,  ncevus  verrucosus,  and  if  covered 
with  coarse  hair,  ncevus  pilosus. 

The  first  form  consists  simply  of  a  circumscribed  hyperpigmentation 
of  the  skin.  In  the  second  and  third  forms,  there  is  often  hypertrophy 
of  connective  and  fatty  tissue. 

Nasvi  may  be  found  on  any  part  of  the  body,  but  their  favorite  sites 
are  the  face,  neck,  and  back.  The  outer  surfaces  of  cerebral  and  spinal 
hernias  are  commonly  covered  by  these  moles. 

The  cause  of  these  localized  hypertrophies  is  unknown.  The  part 
played  by  maternal  impressions  continues  to  be  debatable,  with  the 
balance  of  opinion  against  any  logical  connection. 

Pigmentary  na?vi  may  increase  in  extent  as  the  patients  grow,  and 
show  no  tendency  to  disappear  spontaneously.  In  early  life  they  con- 
stitute merely  blemishes,  but  as  they  are  liable  to  malignant  degenera- 
tion, their  removal  in  childhood  is  advisable, — at  least  in  the  case  of  the 


164  CONGENITAL    MALFORMATIONS 

larger  growths.  This  may  be  done  by  ' '  stippling ' '  with  cautery,  by  elec- 
trolysis, or  excision. 

The  vascular  nasvi  are  made  up  of  anomalous  blood-vessels,  capillary, 
venous,  or  arterial.  Often  they  are  not  perceptible  at  birth,  but  become 
evident  in  the  first  weeks  of  life.  They  vary  greatly  in  size  and  color, 
and  all  are  obliterated  by  pressure.  This  variety  also  selects  the  face 
and  neck  as  favorite  locations,  but  also  occur  on  the  mucous  membranes, 
as  well  as  the  surfaces  of  kidney,  liver,  and  spleen.  The  etiology  is  as 
obscure  as  is  that  of  pigmented  moles. 

Those  most  frequently  seen  are  small,  not  elevated  above  the  skin,  and 
having  vessels  of  capillary  size.  A  large  proportion  of  these  disappear 
without  treatment  in  a  few  months.  The  term  • '  port-wine  mark ' '  is 
applied  to  naavi  of  the  size  of  the  hand  or  larger.  In  these,  distinct  blood- 
vessels are  sometimes  seen  and  the  surfaces  are  often  uneven.  When  these 
nsevi  form  large,  elevated,  lobulated,  erectile,  or  pulsating  tumors  they 
are  termed  angiomata  cavernosa.  They  often  attain  a  large  size  and  are 
a  source  of  danger  to  the  child  from  hemorrhage  following  a  slight  in- 
jury. Later  in  life  they  are  subject  to  degenerative  changes.  The  smaller 
nsevi  should  not  be  interfered  with  in  infancy  or  early  childhood,  as  they 
may  disappear  spontaneously.  If  treatment  be  required  by  the  parents, 
painting  with  collodion  may  cause  obliteration  of  the  small  marks.  For 
the  larger  nsevi,  corrosive  sublimate  and  collodion  (1  :  10)  or  ethylate 
of  soda  may  be  repeatedly  applied,  but  removal  by  electricity  is  the  most 
satisfactory  method  of  treatment. 

CONGENITAL   BONY   DEFECTS — OSTEOGENESIS   IMPERFECTA. 

Several  varieties  of  defective  bony  formation  have  been  described 
under  various  names,  but  there  is  no  uniformity  of  classification. 

Occasionally  at  birth  there  is  absence  or  rudimentary  formation  of 
some  one  of  the  long  bones,  as  the  clavicle  or  bones  of  the  forearm  and 
leg.    Usually  this  defect  is  symmetrical. 

The  occurrence  of  actual  rhachitic  deformities  at  birth  must  be  recog- 
nized, although  rare,  and  many  cases  that  have  been  reported  in  the  past 
as  fetal  rickets  are  now  known  to  be  examples  of  achondroplasia. 

Unusual  fragility  of  the  bones,  fractures  occurring  in  spite  of  the 
greatest  care  or  even  in  atero,  may  be  present  in  the  absence  of  all 
evidence  of  ricke.ts  or  syphilis,  constituting  the  osteogenesis  imperfecta 
of  some  writers.  There  may  be  great  brittleness,  the  bones  consisting  of 
a  very  thin  shell  of  osseous  tissue,  or  they  may  be  so  lacking  in  mineral 
matter  as  to  be  easily  bent  or  cut. 

The  only  known  treatment  is  to  protect  the  bone  from  traumatisms 
and  to  improve  the  general  nutrition  by  all  available  measures. 

ACHONDROPLASIA — CHONDRODYSTROPHY   FETALIS. 

Recognition  of  achondroplasia  and  differentiation  from  cretinism  and 
rickets  are  becoming  general,  owing  to  the  renewed  interest  in  the  disease 
during  the  past  ten  years.     The  essential  points  are  a  dwarfed  stature 


=  w 


tt  'i 

E      I 


3  K 
o5' 


Fig.    107. — Shortened,    curved    bones    of    achondroplasia. 
(Rush  Medical  Museum.) 


Fig.  10S.—  Skiagram  of  achondro- 
plastic  thigh,  showing  enormous  con- 
dyles and  short  femur. 


DYSOSTOSIS  165 

due  to  shortened  limbs,  the  trunk  acquiring  normal  development ;  a  large 
dome-like  head  with  retraction  at  the  root  of  the  nose  from  premature 
ossification  of  the  bones  at  the  base  of  the  skull;  and  unimpaired  men- 
la  lily  (Figs.  104  to  108). 

In  the  extremities  the  shortening  is  particularly  marked  in  the  humeri 
and  femora.  All  the  epiphyses  are  large  and  the  limbs  are  curved  or 
distorted.  The  hands  are  short  and  the  fingers  separate,  forming  the 
trident  hand.    The  distal  phalanges  seem  to  escape  deformity. 

Most  achondroplasiacs  die  soon  after  birth,  but  those  who  survive 
early  childhood  possess  ordinary  health. 

As  the  name  implies,  the  defect  is  in  the  cartilages,  and  the  cause 
must  be  operative  in  the  early  months  of  fetal  life.  Bones  formed  in 
membrane  and  those  developing  from  cartilage  at  a  later  .period  are  not 
involved.  The  thyroid  gland  has  been  reported  normal;  none  of  the 
symptoms  of  cretinism,  excepting  dwarfism,  are  present,  and  thyroid 
extract  offers  no  hope  of  relief. 

CLEIDOCRANIAL   DYSOSTOSIS. 

An  odd  combination  of  congenital  bony  malformations  has  recently 
been  studied  and  reported.  In  these  infants  there  is  aplasia  of  the 
clavicles,  a  flattening  of  the  occiput,  and  an  increased  transverse  diam- 
eter of  the  skull.  The  fontanelles  remain  open  even  to  adult  life,  and 
there  is  defective  development  of  teeth,  palate,  and  other  bones  of  the 
face.  The  mind  is  not  affected.  The  peculiarity  may  be  present  in  sev- 
eral members  of  the  same  family,  also  in  the  second  generation.  Not 
even  a  satisfactory  theory  of  the  etiology  has  been  advanced. 


PART    II 

Diseases  of  Children 

<? 

CHAPTER    I 
DISEASES  OF  THE  NEW-BORN 

EXAMINATION    OF    CHILDREN 

The  first  essential  for  the  successful  study  of  the  manifestations  of 
disease  in  infancy  and  childhood  is  a  thorough  familiarity  with  the  nor- 
mal child  at  various  stages  of  growth.  A  second  essential  is  a  complete 
knowledge  of  the  morbid  tendencies  peculiar  to  the  different  periods  of 
development.  A  third  essential  is  a  recognition  of  the  fact  that  the  un- 
stable equilibrium  of  infancy  and  childhood  responds  to  functional  dis- 
turbances in  a  varied  and  irregular  manner  with  a  frequent  extravagance 
of  symptoms  from  apparently  trivial  causes. 

The  absence  of  all  subjective  symptoms  in  infants  and  young  children 
throws  the  diagnosis  in  this  class  of  patients  entirely  upon  rational  signs 
and  objective  symptoms.  Although  the  science  of  symptomatology  is  the 
same  in  all  classes  of  patients,  the  art  of  its  application  to  diseases  of  early 
life  is  peculiar. 

In  examining  infants  and  children  inspection  must  furnish  the  larger 
part  of  information,  and  the  study  of  symptoms  must  frequently  take 
the  place  of  the  more  exact  diagnostic  measures  of  adult  life.  Xo  routine 
method  may  be  prescribed  in  dealing  with  children.  Tact  and  patience 
are  all-important  and  delay  iu  a  direct  examination  is  often  wise.  If 
the  child  be  sleeping  he  should  not  be  aroused  until  the  opportunity  is 
utilized  for  thorough  inspection.  If  possible,  before  entering  the  nur- 
sery or  sick-room,  the  physician  should  secure  a  complete  history,  in- 
cluding all  possible  items  of  heredity,  birth,  feeding,  growth,  previous 
attacks  of  sickness,  and  manner  of  onset  of  the  present  illness.  In 
securing  the  history,  suggestive  questions  should  be  avoided.  Usually, 
although  it  may  prove  tedious,  the  uninterrupted  narration  of  parent 
or  nurse  will  furnish  valuable  information  to  the  discriminating  doctor. 

An  inspection  during  sleep  may  afford  a  more  truthful  picture  of  the 
child's  condition  than  can  be  secured  in  waking  moments.  First,  the 
decubitus  should  be  observed,  the  relative  position  of  the  head  and  trunk, 
whether  normally  relaxed  or  rigidly  retracted.  The  sleep,  whether  quiet 
or  disturbed,  the  color,  texture,  moisture,  and  temperature  of  the  skin, 
the  respiration,  whether  quiet  and  regular  or  irregular,  sighing  or  noisy 
166 


EXAMINATION    OF    CHILDREN 


167 


from  obstruction  in  the  upper  air-passages,  the  play  of  the  alffi  nasi,  the 
supraclavicular  and  intercostal  depressions  with  inspiration,  and  the 
presence  of  cyanosis,  are  all  important  indications.  The  open  mouth,  the 
half-closed  eyes,  moaning,  and  twitching  of  facial  muscles,  are  also  sig- 
nificant. Does  the  child  lie  "high"  or  with  his  head  burrowed  in  the 
pillow?  The  size  and  tension  of  the  fontanelle  should  be  noted  and  the 
character  and  frequency  of  pulse  compared  with  respiration. 

If  the  child  be  awake,  the  physician  may  do  well  to  seem  to  ignore  his 
presence.  The  egotism  and  timidity  of  children  make  them  suspicious  of 
any  direct  advance,  while,  if  ignored,  their  curiosity,  if  tactfully  utilized, 
may  soon  lead  to  easy  terms  of  acquaintance.  Most  sick  children  resent 
being  stared  at  too  closely.  By  indirect  inspection  there  may  be  noted 
contour,  posture,  muscular  movements,  locomotion,  and  facial  expression, 


Position  for  examination  of  the  chest. 


while  the  ear  takes  cognizance  of  every  sound, — as  crying,  talking, 
breathing,  or  coughing.  If  the  infant  be  over  three  months  of  age,  note 
if  he  holds  up  his  head;  if  six  months,  does  he  sit  unsupported;  if  a 
year  or  more,  does  he  stand  or  walk  without  limp  or  dragging  of  a  foot  ? 
Is  there  a  discharge  from  nose,  eyes,  or  ears  ?  If  the  child  can  be  coaxed 
to  the  doctor's  knee  much  information  may  be  gained  by  taking  advan- 
tage of  the  opportunity  for  palpation,  percussion,  and  auscultation. 

The  child  should  be  stripped,  if  practicable,  and  placed  upon  a  pillow 
on  the  mother's  lap  or  table,  where  thorough  examination  may  be  made 
by  inspection,  palpation,  percussion,  and  auscultation.  It  is  obviously 
impracticable  to  attempt  this  routine  examination  of  a  child  screaming 
and  struggling  in  an  agony  of  fear.  A  little  subterfuge  may  secure  a 
part  where  the  whole  is  denied.     The  infant  held  against  the  nurse's 


168  DISEASES    OF    THE    XEW-BORN 

breast,  with  its  head  over  her  shoulder,  presents  quite  sufficient  dorsal 
surface  for  brief,  immediate  auscultation  and  even  percussion,  if  tact- 
fully employed  (Fig.  109).  The  latter,  to  be  valuable,  must  always  be 
gentle.  Fremitus  or  its  absence  may  be  noted,  and  palpation  of  the  abdo- 
men, limbs,  and  superficial  lymph  nodes  adroitly  secured.  Meanwhile, 
skin  eruptions  and  lesions,  aural  and  nasal  discharges,  texture  of  skin, 
hair,  and  nails  should  all  be  observed. 

Eectal  temperature  should  be  taken  and  may  be  usually  managed 
without  a  struggle.  Eectal  examination  may  be  made,  if  necessary,  even 
in  young  infants,  with  the  lubricated  finger,  and  may  give  information 
as  to  tumors,  intussusception,  appendicitis,  adhesive  peritoneal  bands, 
and  enlarged  lymph  nodes. 

The  physician  should  always  examine  the  infant's  diapers,  not  trust- 
ing to  the  description  of  the  mother  or  nurse,  and,  when  possible,  the 
urine.  For  this  purpose  the  dejections  should  be  saved  until  his  visit. 
Urine  may  be  secured  even  from  young  infants  by  placing  a  pledget  of 
absorbent  cotton  enclosed  in  a  fold  of  rubber  tissue  against  the  genitals. 
For  boys,  a  small  bottle  or  rubber  cot  may  be  employed,  and  for  girls  a 
boat-shaped  vulcanized  receptacle,  retained  in  position  by  a  four-tailed 
bandage  or  by  adhesive  straps  and  diaper.  If  necessary,  catheterization 
should  be  resorted  to,  with  proper  aseptic  precautions. 

The  child's  eyes  may  furnish  valuable  information  in  strabismus, 
nystagmus,  pupillary  reaction  or  inequalities,  corneal  haziness,  phlyc- 
tenular ulcers,  or  amaurosis.  There  may  be  ptosis,  exophthalmos,  or  the 
deflected  visual  axis  of  hydrocephalus,  facial  or  other  voluntary  motor 
paresis,  muscular  dystrophies,  pseudohypertrophy,  exaltation  or  aboli- 
tion of  reflexes,  spasticities,  contractures,  flaccid  paralysis,  bow-legs,  or 
knock-knees,  rhachitic  pseudoparalysis,  bony  enlargements,  tuberculous 
and  syphilitic  epiphysitis,  or  arthritic  tenderness. 

The  mouth  should  always  be  examined  last,  by  which  means  alone 
may  be  determined  the  condition  of  the  tongue,  teeth,  gums,  buccal  sur- 
faces, palate,  tonsils,  and  pharynx.  Without  this  knowledge  no  diag- 
nosis should  ever  be  attempted. 

The  X-ray  is  ofttimes  a  valuable  aid.  not  only  for  the  location  of 
foreign  bodies,  fractures,  dislocations,  bony  deformities,  and  tumors,  but 
for  enlarged  and  displaced  viscera,  areas  of  consolidation  and  exudations. 

ASPHYXIA. 

Ix  the  parturient  chamber  a  most  welcome  sound  is  the  cry  of  the 
child,  not  only  as  a  signal  of  the  termination  of  the  most  difficult  stage 
of  labor,  but  as  an  indication  of  the  establishment  of  the  most  important 
function  of  the  newly  born.  The  experienced  ear  of  the  accoucheur  inter- 
prets that  cry  as  to  its  prognostic  value,  a  loud  and  sustained  quality 
indicating  unquestioned  respirators"  vigor. 

If,  however,  the  cry  be  feeble  or  absent,  his  attention  is  immediately 
engaged  as  to  the  presence  or  absence  of  respiration,  the  depth  and  fre- 
quency of  the  movements  involved,  the  color  of  the  skin,  and  the  action 


ASPHYXIA  169 

of  the  heart.  Pulmonary  respiration  may  not  be  established  immediately 
after  delivery,  and  as  placental  respiration  ceases  with  the  ligation  of 
the  cord,  vital  processes  are  reduced  rapidly,  and  the  child  may  die  of 
asphyxiation, — literally  for  want  of  breath.  The  exact  instant  at  which 
death  occurs  in  these  cases  of  pulmonary  asphyxiation  no  one  can  deter- 
mine, and  probably  no  condition  so  frequently  presents  itself  to  the 
physician  in  which  his  skill  and  timely  services  may  unquestionably 
maintain  the  vital  processes. 

It  is  well  known  that  perseverance  in  his  efforts  is  often  rewarded 
by  the  establishment  of  respiration  in  cases  where,  for  many  minutes, 
the  results  seemed  hopeless.  Occasionally  asphyxiation  occurs  after 
pulmonary  respiration  has  been  established,  at  times  coming  on  suddenly 
with  almost  complete  arrest ;  at  other  times,  gradually,  the  feeble  respi- 
ration becoming  more  and  more  shallow  until  finally  suspended. 

As  before  stated,  there  is  marked  cyanosis  of  the  superficies,  the 
mucosa  particularly  showing  a  deep  purple  hue.  The  general  indications 
of  intense  congestion,  swollen  appearance  of  the  face,  slow,  labored  heart 
action,  all  give  evidence  of  pulmonary  obstruction.  As  the  coma  deepens 
from  accumulation  of  carbon  dioxide,  the  heart's  action  becomes  more 
rapid  and  feeble,  the  extremities  cold,  and  the  surface  pallid,  with  final 
cessation  of  heart  beat.  On  the  other  hand,  there  may  be  from  the  be- 
ginning shallow,  irregular  inspiration,  feeble,  rapid  heart,  colorless  sur- 
face, and  flaccid  limbs,— all  evidences  of  feeble  vital  processes.  These 
two  pictures  represent  different  types  of  suspended  animation,  from 
deficiency  of  oxygen,  and  may  be  due  to  quite  different  causes — the  first, 
to  mechanical  obstruction  to  the  entrance  of  air  from  any  cause ;  the 
second,  to  an  enfeebled  condition  of  the  musculature  of  the  circulatory 
and  respiratory  systems.  Between  these  two  distinct  types — namely, 
asphyxia  livida  and  asphyxia  pallida — many  variations  may  occur. 

In  his  efforts  for  the  relief  of  asphyxia  neonatorum,  the  term  applic- 
able to  all  of  these  conditions,  the  physician  must  be  governed  by  the 
type  to  which  the  individual  case  most  inclines.  Efforts  at  cardiac  or 
respiratory  stimulation  are  entirely  out  of  order  wiien  the  trouble  is  due 
to  mechanical  obstruction  from  inspired  mucus  in  the  glottis  or  fluids 
in  the  pulmonary  tubes.  On  the  other  hand,  worse  than  useless  are  such 
violent  measures  as  artificial  respiration  by  swinging  through  the  air 
the  chilled  body  of  the  pallid  infant,  whose  fluttering  heart  shows  the 
need  of  warmth  and  cardiac  support.  Fortunately,  asphyxia  may  be  re- 
lieved by  prompt  aid  in  a  great  majority  of  cases,  particularly  of  the 
sthenic  variety,  and  occasionally  of  the  asthenic  type. 

The  indications  are  plain, — viz.,  the  removal  of  obstruction  from  the 
respiratory  passages,  whether  nasal,  pharyngeal,  laryngeal,  or  tracheal. 
As  mentioned  in  a  previous  chapter,  the  first  may  be  accomplished  by 
a  pledget  of  absorbent  cotton ;  the  second,  by  a  finger  wrapped  with  dry 
gauze.  The  glottis  may  be  freed  from  tenacious  secretion  sometimes  by 
skilful  manipulation  of  a  curved  canula,  with  bulb  attachment  for 
exhaustion  of  the  air,  or  by  direct  suction  through  a  catheter  by  the 


170  DISEASES    OF    THE    NEW-BORN 

mouth  of  the  operator.  These  efforts  should  be  aided  by  inversion 
of  the  child,  thus  securing  the  influence  of  gravity  in  the  escape  of  fluids, 
and  also  determination  of  blood  to  the  medulla.  Artificial  respiration 
should  be  practised  when  there  is  suspended  action  from  feebleness  of 
the  respiratory  muscles.  Alternating  hot  and  cold  applications  and  fara- 
dization for  cardiac  as  well  as  respiratory  stimulation  may  be  useful. 

Rhythmic  traction  of  the  tongue  is  sometimes  successful  in  establish- 
ing respiration.  Too  often  a  vital  requirement  is  overlooked  in  allowing 
the  infant  to  become  chilled, — warmth  being  of  the  greatest  importance. 

INSPIRATION   PNEUMONIA   OF   THE   NEWLY   BORN. 

There  is  a  popular  belief  that  the  infant  is  sometimes  ' '  born  with  a 
cold,"  in  corroboration  of  which,  symptoms  of  catarrhal  involvement 
of  the  bronchial  tree,  including  cough,  dyspnoea  and  fever,  are  cited. 
In  brief,  the  classical  symptoms  and  sometimes  signs  of  infantile  broncho- 
pneumonia are  seen  in  the  new-born.  Inspiration  pneumonia  is  a  term 
applied  to  the  condition.  The  infection  is  evidently  due,  as  the  term  im- 
plies, to  material  drawn  into  the  lungs  of  the  infant  during  his  passage 
through  the  parturient  canal,  and  presupposes  the  presence  of  micro- 
organisms, or  the  pre-existence  of  endometritis,  vaginitis,  eto. 

The  treatment  is  chiefly  prophylactic  and  should  be  directed  toward 
early  disinfection  of  the  birth  canal.  As  to  the  infant,  the  existence  of 
a  lobular  pneumonia  requires  supporting  measures,  stimulation,  rest,  etc. 

CYANOSIS   INFANTUM. 

The  term  "  blue  baby'.'  is  frequently  used  by  the  laity,  and  the  title, 
morbus  cmruleus,  is  occasionally  seen  in  the  older  literature.  Broadly 
speaking,  it  is  applicable  to  any  form  of  cyanosis,  and  includes  in  its 
etiology  all  the  causes  of  deficient  oxygenation  of  the  blood.  The 
term  is  usually  applied  to  infants  with  congenital  malformations  or 
structural  defects  of  the  heart  and  great  vessels  (see  Congenital  Heart 
Disease).  With  few  exceptions  it  is  the  right  heart  that  is  affected, 
the  most  frequent  lesion  being  stenosis  of  the  pulmonary  orifice,  with 
or  without  anomaly  of  its  valves.  The  patulous  foramen  ovale  and 
ductus  arteriosus,  formerly  considered  the  causative  lesions,  are  now 
regarded  as  secondary  to  the  pulmonary  obstruction.  So,  too,  as  a  result 
of  increased  pressure  in  the  right  ventricle  must  be  regarded  the  occa- 
sional incomplete  ventricular  septum.  A  long  continuance  of  pulmonary 
stenosis  usually  results  in  enormous  hypertrophy  of  the  right  heart. 
The  skin  does  not  always  exhibit  the  distinctive  hue,  but  occurrences  of 
cyanosis  are  induced  upon  active  exertion,  and  if  the  patient  survive 
to  the  age  of  childhood,  the  finger-tips  show  the  characteristic  clubbing 
due  to  retarded  circulation.  This  disorder  may  arise  from  a  variety  of 
vasculo-cardiac  malformations  regarded  as  pathologic  curiosities,  the 
differentiation  of  which  is  extremely  difficult  prior  to  the  autopsy. 

The  prognosis  and  treatment  depend  largely  upon  the  symptoms, 
drugs  proving  of  but  little  avail.     Freedom  from  exertion  and  excite- 


INANITION    FEVER  171 

ment  is  absolutely  necessary  for  comfort  and  safety.     Though  the  mor- 
tality is  high,  the  patient  not  infrequently  survives  to  maturity. 

ATELECTASIS. 

In  many  infants  at  birth  the  inflation  of  the  lungs  is  not  complete, 
a  portion  retaining  its  fetal  condition.  This  state,  known  as  atelectasis, 
probably  obtains  to  a  limited  extent  in  all  new-born  during  the  first  few 
days ;  the  atelectatic  portions  gradually  expanding  with  the  normally  in- 
creasing vigor  of  respiration.  It  is  usually  the  lower  posterior  borders 
that  remain  unexpanded,  although  their  consolidation  is  often  masked 
by  the  emphysematous  condition  of  overlying  superficial  vesicles.  In 
fact,  the  extent  or  even  the  existence  of  congenital  atelectasis  is  rarely 
diagnosed  by  physical  signs,  this  condition  being  most  frequently  indi- 
cated by  the  symptoms.  Slight  degrees  of  atelectasis  may  produce  no 
symptoms,  the  condition  escaping  notice  entirely.  Shallow,  rapid  respi- 
rations, recurring  cyanosis,  feeble  cry,  and  subnormal  temperature  with 
tendency  to  collapse,  are  symptoms  strongly  indicative  of  unexpanded 
lung.  Atelectasis  may  be  due  to  any  of  the  causes  of  asphyxia  neona- 
torum. Paresis  of  the  respiratory  centres,  brain  pressure,  and  prema- 
ture birth  are  also  frequent  factors. 

Long  continued  maintenance  of  one  position  favors  atelectasis, 
through  interference  in  circulation  from  pressure  and  hypostasis.  By 
reference  to  the  chapter  on  Hygiene  of  the  New-born,  it  is  seen  that 
frequent  changing  of  position  and  occasional  massage  are  advised.  Hence 
one  objection  to  institutional  management  of  infants  is  that  they  are  con- 
fined too  closely  to  cribs,  leading  a  purely  vegetative  existence.  As  pre- 
viously stated,  lung  capacity  is  the  exponent  of  infant  vitality.  Hence 
it  necessarily  follows  that  impairment  of  vitality  is  in  direct  ratio  to  the 
extent  of  unexpanded  lung.  The  atelectatic  condition  is  susceptible  of 
spontaneous  correction,  failing  in  which  it  continues  a  menace  to  life. 
Fatal  ending  of  a  mild  bronchitis  is  often  due  to  pre-existing  atelectasis. 

The  treatment  is  purely  rational, — viz.,  efforts  to  secure  expansion 
through  deep  inspiration.  For  this  purpose  prolonged  crying,  short  of 
exhaustion,  must  be  encouraged.  Massage,  flagellation,  and  sprinkling 
the  chest  with  cold  water  will  assist.  The  longer  the  condition  persists 
the  more  difficult  will  be  its  correction.  Hence  early  efforts  should  be 
continued.  Fresh  air  supply  and  maintenance  of  bodily  warmth  are 
especially  insisted  upon,  nor  must  it  be  forgotten  that  the  defective  lung 
will  poorly  endure  pressure,  as  from  distended  abdominal  viscera,  sud- 
den death  from  this  added  cause  being  not  infrequent.  For  threatened 
collapse  due  to  respiratory  enfeeblement,  inhalation  of  oxygen  and  hypo- 
dermics of  strychnia  are  indicated. 

The  prognosis  depends  upon  the  extent  of  involvement  and  the  per- 
sistence of  the  condition. 

INANITION   FEVER. 

Within  the  last  few  years  attention  has  been  called  to  the  develop- 
ment of  pyrexia  in  infants  during  the  first  four  days  of  life.     A  want 


172  DISEASES    OF    THE    NEW-BORN 

of  nutrition  seems  to  be  the  sole  etiologic  factor,  as  in  these  cases  there 
is  a  rapid  disappearance  of  the  fever  upon  the  administration  of  proper 
nourishment.  This  inanition  fever  has  been  frequently  observed,  and, 
for  the  present  at  least,  must  take  its  place  in  the  nosology  of  the  new- 
born. From  the  first  to  the  fourth  day  of  extrauterine  life  the  tempera- 
ture may  range  from  99.5°-106°  F."(37.5°-41°  C),  approaching  the 
normal  usually  abruptly  upon  the  establishment  of  lactation  or  upon 
the  administration  of  artificial  food.  In  these  febrile  cases  it  has  been 
noticed  that  the  loss  of  weight  is  more  marked  than  in  the  nonfebrile. 
The  importance  of  recognizing  this  condition  from  the  pyrexias  due  to 
known  infections  is  apparent.  The  treatment  would  call  for  properly 
attenuated  artificial  food.  By  this  means  it  is  believed  that  the,  so-called, 
normal  loss  of  weight  may  be  reduced  to  the  minimum,  if  not  altogether 
prevented. 

It  is  known  that  inanition  fever  may  cause  death  at  this  early  age, 
even  when  the  child  is  apparently  taking  the  breast  normally.  It  is 
the  duty  of  the  physician  to  assure  himself  that  the  child  is  actually 
getting  a  sufficient  amount  of  suitable  food,  and  the  first  sign  of  pyrexia 
or  failure  to  gain  in  weight  should  lead  to  examination  of  the  breast  and 
its  secretion.    Water,  of  course,  is  always  indicated. 

ANURIA. 

Anuria  in  the  new-born  is  a  condition  that  has  received  too  little  atten- 
tion. It  may  range  from  a  trivial  functional  disturbance  to  the  gravest 
organic  lesion,  and  such  a  variety  of  causes  may  obtain  in  this  condition 
that  the  question  of  early  micturition  must  ever  be  regarded  as  one  of 
importance.  A  new-born  child,  who  has  not  urinated  during  the  first 
twenty-four  hours  of  life,  demands  special  care  at  the  hands  of  the 
physician.  The  causes  of  anuria  may  be  stated  briefly,  as  occlusion 
of  the  urethra,  ureters,  or  renal  tubules,  or  the  obliteration  of  the 
secreting  structures  by  cystic  degeneration,  inflammation,  or  neoplastic 
growths.  The  urethra  may  be  occluded  by  a  mucous  plug  or  the  meatus 
closed  by  a  gummy  secretion  sufficient  to  prevent  the  outflow  of  urine. 
The  ureters  may  be  blocked  by  calculi  or  the  uriniferous  tubules  may  be 
plugged  by  uric  acid  crystals.  The  extrusion  of  urine  may  be  prevented 
by  pressure  from  tumors,  abnormal  anatomical  relationship,  or  by  torsion, 
flexion,  or  constriction  of  the  ureters.  The  urethra  may  be  imperforate 
from  arrested  development. 

Without  entering  into  the  differentiation  of  the  various  causes  of 
anuria,  it  should  be  stated  here  that  the  physician  must  satisfy  himself 
of  the  patency  of  the  lower  urinary  apparatus,  the  absence  of  neoplastic 
growths  and  cystic  degeneration  before  venturing  upon  a  favorable  prog- 
nosis. Even  then,  fatal  terminations  have  occurred  where  the  post-mor- 
tem showed  no  abnormality  other  than  a  persistent  general  blocking  of 
the  tubuli  uriniferi  with  uric  acid. 

In  a  large  majority  of  these  cases  urination  is  established  by  merely 
freeing  the  urethra  and  by  a  liberal  use  of  water,  which  presumably 


SCLEREMA    NEONATORUM  L73 

dissolves  the  uric  acid  concretions  and  prevents  their  reaccumulation  by 
flushing  out  the  tubules.  Water  should  be  administered  not  only  by 
mouth,  but  also  by  free  colonic  flushing,  while  elimination  by  the  intes- 
tinal tract  should  be  promoted  by  repeated  doses  of  calomel.  To  these 
may  be  added  hot  baths  and  fomentations  over  the  lumbar  and  hypogas- 
tric regions.  Diuretics  other  than  water  are  of  doubtful  utility,  with  the 
exception,  perhaps,  of  a  modified  simola  mixture  (Formula  38),  of  which 
a  teaspoonful  may  be  given  four  to  six  times  a  day. 

Strange  as  it  may  appear,  convulsions  due  to  anuria  alone  are  of 
rare  occurrence,  and,  when  present,  constitute  one  of  the  late  symptoms. 

SCLEREMA    NEONATORUM. 

Sclerema  neonatorum,  representing  a  condition  rather  than  a  disease, 
is  rarely  seen  in  this  country,  although  it  is  reported  as  of  not  infre- 
quent occurrence  in  European  institutions.  As  its  name  signifies,  the 
characteristic  feature  is  a  hardening  and  condensation  of  the  skin,  which 
process  extends  to  the  subcutaneous  fat  and  areolar  tissue.  It  is  not  a 
true  cedema,  as  there  is  no  pitting  on  pressure.  This  disease  is  sometimes 
congenital,  occurring  oftenest  in  premature  infants,  and  is  frequently 
associated  with  pulmonary  atelectasis. 

Beginning  upon  the  dorsum  of  the  foot  or  in  the  cheeks,  the  indu- 
ration extends  rapidly  to  other  portions,  usually  to  the  fatty  cushions 
of  the  body,  as  the  nates,  and  may  within  a  few  days  involve  the  entire 
cutaneous  surface.  The  skin  has  a  hard  feel,  and  cannot  be  picked  up 
or  moved  upon  the  subjacent  tissues,  giving  a  rigidity  to  the  whole 
body  as  though  encased  in  leather.  At  times  the  stiffness  renders  nurs- 
ing impossible  from  inability  to  move  the  jaw.  The  temperature  is  in- 
variably subnormal,  having  been  observed  as  low  as  80°  F.  (27°  C). 
The  heart 's  action  is  slow  and  feeble,  and  the  respiration  is  retarded  and 
shallow.  Discoloration  is  commonly  observed,  a  dusky  or  somewhat  icter- 
oid  hue  prevailing.  Death  is  the  usual  termination  within  the  first  week. 
Occasionally  recoveries  are  noted  after  a  somewhat  prolonged  conva- 
lescence. 

The  most  rational  etiology  of  this  strange  disorder  is  that  of 
solidification  of  the  subcutaneous  fat  from  continuously  lowered  tem- 
perature incident  to  malnutrition  and  atrophic  conditions.  It  is  claimed 
that  the  fat  of  the  infant  solidifies  at  86.6°  F.  (30°  C),  while  that 
of  the  adult  withstands  a  temperature  below  32°  F.  (0°  C).  The  fat 
of  infants  being  rich  in  palmitine  and  stearine  may  explain  its  ready 
solidification. 

In  the  treatment,  attention  should  be  specially  paid  to  artificial  heat, 
the  couveuse  being  admirably  adapted  to  the  purpose.  Cardiac  and 
respiratory  stimulation,  with  the  exhibition  of  alcohol,  should  be  em- 
ployed, and  nutrition  be  kept  up  by  forced  feeding  and  nutrient  ene- 
mata,  care  being  observed  not  to  embarrass  the  feeble  heart  and  respira- 
tion by  overdistention  of  the  stomach. 

Ichthyosis  (see  Diseases  of  the  Skin). 


174  DISEASES    OF    THE    NEW-BORN 

OBSTETRICAL   PARALYSIS — PERIPHERAL   BIRTH   PALSY;     ERB'S  PALSY. 

Paralysis  resulting  from  injury  to  the  peripheral  nerve-trunks  is  not 
an  uncommon  accident  of  birth.  Of  most  frequent  occurrence  is  facial 
paralysis,  usually  unilateral,  due  to  pressure  upon  the  trunk,  or  some 
of  the  branches  of  the  seventh  nerve,  by  the  forceps  blade.  It  may 
also  be  due  to  prolonged  pressure  contact  with  some  bony  prominence 
of  the  birth  canal,  as  the  promontory  of  the  sacrum  or  the  tuberosity 
of  the  ischium.  The  muscles  involved  may  be  all  of  those  included 
in  the  distribution  of  the  facial  nerve,  if  the  traumatism  occur  proximal 
to  its  main  bifurcation,  or  only  those  muscles  supplied  by  the  temporo- 
f  aeial,  if  the  pressure  has  been  exerted  higher  up  on  the  cheek. 

Although  the  paralysis  no  doubt  immediately  follows  the  injury,  it 
may  escape  early  observation  if  confined  to  the  muscles  of  the  upper  face, 
as  the  symptoms  may  be  masked  by  the  puffiness  of  the  palpebral  tissues 
so  commonly  seen  after  delivery.  If  the  muscles  of  the  cervico-facial 
distribution  are  affected,  however,  the  first  crying  of  the  child  will  reveal 
the  asymmetry,  the  mouth  being  drawn  towards  the  unaffected  side.  The 
tongue,  of  course,  is  not  involved.  Later,  upon  subsidence  of  the  birth 
oedema,  the  entire  side  of  the  face  may  show  obliteration  of  character- 
istic curves,  with  inability  to  close  the  eye,  and  slight  ptosis  of  the  lid. 

Nursing  is  never  interfered  with,  as  this  is  accomplished  largely  by 
the  jaws  and  tongue,  although  the  inaction  of  the  buccal  structures  may 
allow  the  retention  of  particles  of  milk  between  the  gums  and  cheek  on 
the  affected  side. 

The  diagnosis  from  palsy  of  cerebral  origin  is  not  difficult,  if  it  be 
remembered  that  facial  palsy  due  to  central  lesion  above  the  pons  shows 
hemiplegia  of  the  opposite  side.  Moreover,  the  muscles  supplied  by  the 
temporal  branches  of  the  facial  nerve  escape. 

Recovery  usually  takes  place  in  from  a  few  days  to  a  few  weeks  de- 
pendent upon  the  extent  of  injury  to  the  nerves. 

Less  common  than  the  facial  is  the  upper  arm  type  of  birth  paralysis 
from  injury  to  some  cord  of  the  brachial  plexus.  The  arm  hangs  help- 
less at  the  side,  the  forearm  extended  and  in  pronation,  the  palm  facing 
outward  and  backward.  The  muscles  of  the  hand  and  fingers  are  not 
involved  in  this  motor  paralysis.  The  arm  often  appears  slightly  swollen, 
and  its  temperature  is  lower  than  that  of  its  fellow.  The  plexus,  or 
nerve  trunk,  most  frequently  the  fifth  cervical,  may  be  injured  during 
birth  by  pressure  of  the  finger  or  blunt  hook  in  the  axilla  in  efforts  to 
bring  down  the  arm,  or  the  misplaced  forceps  blade  may  impinge  upon 
this  nerve  or  upper  part  of  the  plexus  in  the  neck.  The  nerve  may  also 
be  stretched  or  lacerated  by  undue  traction  upon  the  arm,  or  in  breach 
presentation  the  clavicle  may  be  forced  upward  and  backward  so  as  to 
compress  the  nerve  upon  the  transverse  processes  of  the  fifth  and  sixth 
cervical  vertebrae.  It  has  been  claimed  that  constriction  of  the  neck  by 
coils  of  the  umbilical  cord  may  produce  this  result. 

This  form  of  paralysis  is  readily  diagnosed  at  the  time  of  its  occur- 
rence.    When  first  seen,  after  long  duration,  the  differentiation  from 


PARALYSIS  175 

anterior  poliomyelitis  may  present  some  difficulties.  However,  spinal 
paralysis  rarely  results  in  upper  monoplegia.  The  group  of  muscles  in- 
volved in  Erb's  paralysis  is  characteristic,  and  usually  a  history  of  diffi- 
cult labor  is  secured. 

Differentiation  from  fracture  of  the  humerus  or  epiphysis  may  be 
made  from  the  absence  of  surgical  signs  of  these  accidents,  by  the  charac- 
teristic position  of  the  hand  above  described,  and  by  the  electrical  re- 
action of  the  muscles,  which  is  changed  only  in  the  neuritis.  From  cere- 
bral palsy,  with  its  flexed  arm,  spasticity,  and  hemiplegia,  this  flaccid, 
monoplegic,  peripheral  paralysis  is  readily  distinguished. 

The  prognosis  is  favorable  as  to  ultimate  recovery  in  the  majority 
of  cases.  Extensive  injury,  followed  by  parenchymatous  neuritis,  may 
result  in  permanent  paralysis  with  extreme  and  rapidly  developing  atro- 
phy. Contraction  of  the  subscapularis  may  cause  dislocation  of  the 
humerus.  The  question  of  duration  depends  upon  the  electrical  reaction 
of  the  affected  muscles.  Early  recovery  may  be  expected  in  the  presence 
of  faradic  response,  and  a  decrease  or  diminution  in  the  reaction  of 
degeneration  is  a  hopeful  indication.  Return  of  faradic  excitability 
gives  promise  of  speedy  recovery.  The  deltoid  is  the  last  of  these  mus- 
cles to  recover  its  function,  and  its  atrophy  is  the  most  prominent  fea- 
ture of  the  resultant  deformity. 

Peripheral  paralysis  of  the  lower  extremities,  from  injury  to  the 
lumbar  and  sacral  plexuses  is  almost  unknown,  because  of  the  thorough 
protection  afforded  these  structures  by  the  adjacent  muscles  and  adi- 
pose tissue.  Paraplegia  from  hemorrhage  into  the  spinal  cord  or  its 
meninges,  from  laceration  during  delivery,  has  been  reported,  but  is 
extremely  rare. 

The  treatment  of  obstetrical  paralysis,  like  that  of  other  traumatic 
neuritides,  requires  rest  to  the  dependent  limb.  This  is  best  secured  by 
wrapping  the  flexed  arm  in  cotton  wool,  with  support  as  in  the  treatment 
of  a  fractured  clavicle.  No  massage  or  electricity  should  disturb  the 
injured  structures  during  the  first  two  or  three  weeks,  nor  is  any  treat- 
ment necessary  if  early  signs  of  recovery  are  evident.  If  the  affected 
muscles  show  little  or  no  response  to  faradization  at  the  end  of  a  month, 
the  treatment  should  be  massage  and  passive  motion,  with  a  mild  gal- 
vanic current,  for  a  few  minutes  each  day. 

Later  contractures  may  be  prevented  by  the  application  of  padded 
splints.  If  after  six  months  there  is  no  improvement  in  the  affected 
muscles,  as  seen  in  the  reaction  of  degeneration,  the  question  of  surgical 
procedure  for  the  artificial  anastomosis  of  the  affected  nerve  with  some 
healthy  trunk  should  be  considered.  Recent  reports  of  grafting  from 
the  spinal  accessory  and  hypoglossal,  in  nerve  degeneration  following 
this  form  of  neuritis,  are  encouraging,  and  justify  hope  for  the  few  cases 
of  obstetrical  palsy  that  are  refractory  to  medical  treatment. 


CHAPTER    II 

INFECTIOUS    AND    HEMORRHAGIC    DISEASES    OF    THE 

NEW-BORN 

SUSCEPTIBILITY 

The  thinness  and  delicacy  of  the  skin  and  mucous  membrane  partly 
account  for  the  ease  with  which  infection  occurs  in  new-born  infants. 
A  satisfactory  explanation  of  the  great  susceptibility  shown  at  this  time 
is  yet  to  be  made,  and  the  following  can  only  be  stated  as  facts :  that 
there  exists  a  marked  lowered  resistance  to  the  invasion  of  many  bacteria 
and  that  the  symptoms  are  often  obscure,  as  there  is  more  or  less  absence 
of  the  reaction  seen  in  the  adult.  Moreover,  sepsis  is  particularly  apt 
to  be  attended  by  hemorrhages,  not  only  from,  and  in  the  skin,  but  also 
from  mucous  membranes  and  in  all  viscera. 

Among  the  diseases  positively  and  probably  due  to  infection  are 
mastitis,  inspiration  pneumonia,  ophthalmia  neonatorum,  icterus,  pem- 
phigus, omphalitis,  umbilical  arteritis  and  phlebitis,  tetanus,  erysipelas, 
hemorrhages,  acute  fatty  degeneration,  and  epidemic  hemoglobinuria. 

MASTITIS   NEONATORUM. 

During  the  first  week  of  life  it  is  not  unusual  for  the  infant's  mam- 
mary glands  to  show  undue  prominence.  Upon  pressure  there  exudes 
a  whitish  fluid  resembling  breast  milk,  with  which,  in  fact,  it  is  iden- 
tical. This  curiosity  is  all  the  more  interesting  in  that  it  may  occur  in 
both  sexes.  The  old  dames  of  the  lying-in  chamber  not  infrequently 
consider  the  expression  of  this  secretion  as  a  part  of  the  infant's  toilet, 
as  a  result  of  the  old  superstition  that  by  the  removal  of  this  ' '  witches ' 
milk"  future  trouble  might  be  averted.  Whatever  may  be  the  prophy- 
lactic benefit,  certain  it  is  that  as  a  result  of  this  rough  usage,  the  gland 
sometimes  becomes  infected  and  mastitis  follows.  That  this  mastitis  of 
the  new-born  is  always  dependent  upon  traumatism  is  difficult  of  demon- 
stration. That  it  is  an  infection  from  the  entrance  of  septic  bacteria 
from  without,  is  unquestionable,  and  occasionally  it  results  in  extensive 
suppuration  and  breaking  down  of  tissue. 

Its  treatment  should  be  prophylactic,  care  being  necessary  to  prevent 
irritation  of  the  enlarged  glands  from  pressure  of  clothing,  especially 
of  the  tight  abdominal  band.  In  case  of  abscess,  evacuation  and  dress- 
ing with  the  usual  antiseptic  precautions  are  necessary. 

ICTERUS   NEONATORUM. 

More  or  less  icterus  during  the  first  few  days  of  life  is  so  common 
!hut  many  authorities  regard  it  as  physiological.    A  number  of  lying-in 
176  * 


ICTERUS  177 

institutions  record  as  high  as  sixty  and  even  eighty  per  cent,  of  jaundice 
in  infants  born  therein.  These  figures  must  include  cases  in  which  the 
staining  of  the  skin  is  not  general,  or  so  slight  as  to  be  revealed  only 
after  pressure  with  the  finger.  The  yellow  tinge  appears  usually  the 
third  day  of  life,  gradually  replacing  the  earlier  boiled-lobster  hue,  and 
continues  from  seven  to  ten  days  with  no  untoward  symptoms.  Many 
observers  have  noted,  however,  that  the  majority  of  icteroid  infants  are 
not  so  vigorous  and  show  greater  loss  of  weight,  which  is  more  slowly 
regained,  than  in  the  normal  infant. 

The  more  marked  cases  show  discoloration  of  the  sclera,  presence  of 
bile  in  the  urine  and  its  absence  from  the  stools.  Many  theories  have  been 
advanced  in  explanation  of  this  mild  form  of  icterus  neonatorum,  among 
which  are  rapid  disintegration  of  red  blood-corpuscles  following  birth, 
with  release  of  hematin  into  the  tissues ;  oedema  of  Glisson  's  capsule 
from  prolonged  hepatic  stasis  due  to  pressure  or  constriction  of  the  cord 
during  parturition ;  and  the  persistent  patency  of  the  ductus  venosus, 
diverting  an  undue  portion  of  portal  blood  containing  bile  pigment  from 
its  passage  through  the  liver.  It  is  also  claimed  that  the  sudden  diminu- 
tion of  pressure  in  the  hepatic  vessels  which  follows  the  change  of  circu- 
lation from  fetal  to  postnatal  life  allows  the  escape  of  bile  from  the 
hepatic  ducts  to  adjoining  blood-vessels  by  osmosis.  Occasional  post- 
mortems upon  infants,  dying  while  jaundiced,  have  shown  occlusion  of 
the  common  bile-duct  by  a  tenacious  mucous  plug. 

Treatment. — It  is  evident  that  no  specific  treatment  is  indicated  in 
these  mild,  transient  forms  of  infantile  jaundice,  other  than  careful  feed- 
ing and  attention  to  hygiene,  with  the  free  administration  of  water. 

Occasionally  a  pseudo jaundice  is  observed  from  the  inordinate  use 
of  saffron  tea,  with  which  the  infant  has  been  dosed  for  supposed  intes- 
tinal disturbance. 

GRAVE   ICTERUS. 

The  preceding  form  of  simple  icterus  neonatorum  must  be  differ- 
entiated from  jaundice,  accompanied  by  grave  conditions,  such  as  con- 
genital occlusion  of  the  bile  ducts ;  umbilical  phlebitis ;  hepatitis,  spe- 
cific or  non-specific;  acute  fatty  degeneration  (Buhl's  disease),  and  in- 
fectious hemoglobinuria  (Winckel's  disease).  Congenital  occlusion'  of 
the  common,  hepatic,  or  cystic  duct  is  presumably  due  to  a  prenatal 
peritonitis  extending  to  the  ducts,  or  to  pressure  accompanying  or  inci- 
dent thereto.  Mere  atresia  of  the  common  duct  at  its  duodenal  orifice 
may  be  the  result  of  intrauterine  duodenitis.  Absence  of  the  large  bile 
ducts,  also  of  the  gall-bladder,  has  been  noted  and  explained  both  on  the 
ground  of  the  result  of  intrauterine  inflammation,  and  of  arrested  de- 
velopment. To  the  latter  cause,  also,  is  attributed  imperviousness  of  the 
common  duct  which  appears  embryologically  as  a  solid  cord,  its  lumen 
developing  later.  If  the  occlusion  have  existed  for  any  considerable  time 
in  utero,  the  meconium  will  be  light  in  color.  Tarry  meconium  dues  not 
preclude  congenital  stenosis  of  more  recent  occurrence.     The  icterus  is 

12 


178  DISEASES    OF    THE    NEW-BORN 

marked,  including  the  selerotics ;  the  urine  is  dark  brown,  and  post-mor- 
tems show  bile-staining  of  all  the  tissues. 

The  liver  and  spleen  may  be  both  enlarged.  The  abdomen  may  be 
further  distended  by  intestinal  flatus.  Diarrhoea  may  occur  with  fre- 
quent watery,  light-colored  stools;  or  constipation  with  putty-  or  clay- 
colored  stools  may  be  the  rule.  Umbilical  hemorrhage  may  result  from 
congestion  of  the  portal  vessels.  The  temperature  is  rarely  above  the 
normal,  usually  below.  The  infant  fails  to  gain  in  weight,  inclines  to 
somnolence,  loses  appetite,  and  dies  from  general  asthenia,  in  coma  or 
convulsions,  in  from  six  weeks  to  six  months.  Death  may  be  hastened  by 
umbilical  or  other  hemorrhages  or  by  acute  intercurrent  disorders. 

Since  no  medical  treatment  avails  and  early  death  is  assured,  surgical 
interference  would  seem  to  suggest  the  only  relief  from  the  persistent 
cholaemia. 

PEMPHIGUS   NEONATORUM. 

Pemphigus  in  the  new-born  presents  at  least  two  forms,  syphilitic  and 
non-syphilitic.  In  the  first,  the  bullous  eruption  is  present  at  birth  or 
develops  soon  after,  in  emaciated,  cachectic  children.  The  lesions  are 
small,  flabby,  and  dull-colored,  having  a  livid  base.  Wherever  else  they 
may  be  located,  the  palms  and  soles  are  sure  to  contain  some  of  the 
lesions.  Other  signs  of  congenital  syphilis  are  usually  present.  The 
course  of  the  disease  is  slow,  with  occasional  intervals  of  improvement, 
but  the  child  usually  dies  of  cachexia  or  of  some  intercurrent  disease. 

The  non-syphilitic  form  is  doubtless  contagious,  as  epidemics  in  hos- 
pitals and  neighborhoods  have  occurred.  The  ordinary  pus  germs  are 
present  in  the  fluid  filling  the  vesicles,  but  it  is  difficult  to  accept  them 
as  more  than  accompanying  the,  as  yet,  undiscovered  infective  micro- 
organism. 

The  bulla?  are  considerably  larger  than  those  of  the  syphilitic  variety, 
do  not  appear  for  several  days  after  birth,  and  the  favorite  sites  are 
the  abdomen  and  buttocks,  but  very  rarely  are  they  seen  on  the  palms 
and  soles.  The  lesions  may  develop  on  any  other  portion  of  the  body 
and  even  on  the  mucous  membrane.  During  an  epidemic,  healthy  chil- 
dren as  well  as  the  delicate  yield  to  the  infection.  While  only  a  few 
lesions  are  present,  there  may  be  no  evidence  of  systemic  disturbance, 
but  with  a  generalized  eruption  there  is  likely  to  be  considerable  pyrexia, 
restlessness,  and  vomiting. 

The  points  of  entrance  for  the  infective  agent  are  abrasions  in  the 
easily  lacerated  skin  of  the  new-born  infant.  Naturally,  the  umbilicus 
is  frequently  involved — periumbilical  pemphigus.  In  this  form  the  base 
presents  a  reddened  areola.  The  bulla  are  easily  ruptured,  allowing 
the  escape  of  the  serous,  bloody,  or  purulent  contents,  and  leaving  a 
moist,  reddened  surface.  This  forms  a  superficial  ulcer  that,  in  the 
majority  of  cases,  quickly  heals. 

Complications,  such  as  empyema,  gangrene,  or  general  sepsis,  are 
occasionally  seen,  but  the  prognosis  is  better  than  in  adults. 


TETANUS    NEONATORUM  179 

Prophylaxis  by  isolation  of  the  patient  and  careful  disinfection  of 
attendants,  should  he  strictly  enforced.  It  also  excludes  rough  handling 
of  the  infant's  skin.  As  curative  measures,  incision  of  each  bulla  and 
the  application  of  fifty  per  cent,  ichthyol  ointment  are  advised.  Some 
prefer  disinfecting  baths,  gentle  drying,  and  the  use  of  dusting  powders, 
— as  boric  acid,  salicylic  acid,  and  oxide  of  zinc. 

OMPHALITIS. 

The  navel  is  the  portal  most  liable  to  infection  by  bacteria  from 
attendants'  hands,  the  dressing  of  the  cord,  and  from  the  clothing. 
Omphalitis  may  develop  in  from  three  days  to  as  many  weeks  after 
birth,  and  is  indicated  by  a  ring  of  reddened,  swollen,  and  painful  tissue 
around  the  stump.  The  inflammation  may  be  localized,  in  which  case 
the  prognosis  is  good  under  simple  warm  boric  acid  dressings.  A  less 
favorable  course  is  extension  over  a  large  surface  of  the  abdomen,  in- 
volving the  deeper  tissues  or  through  the  umbilical  arteries  or  veins, 
resulting  in  general  sepsis. 

In  addition  to  the  surgical  care  of  the  superficial  area  of  inflammation, 
stimulation  is  indicated. 

TETANUS. 

Tetanus  is  rarely  seen  in  new-born  infants.  The  umbilicus  is  doubt- 
less the  most  frequent  point  of  entrance  for  the  bacillus.  It  has  ap- 
peared as  early  as  the  second  day  of  life,  and  seldom  develops  later  than 
the  fifteenth. 

Trismus,  rendering  nursing  difficult,  is  the  first  symptom  noted.  The 
spasms  rapidly  involve  the  muscles  of  the  face,  trunk,  and  extremities,, 
followed  by  distinct  convulsions,  alternating  with  intervals  of  partial 
relaxation.  Death  in  spasms  or  coma  usually  occurs  by  the  second  or 
third  day. 

The  prevention  of  tetanus  by  cleanliness  is  obligatory  with  every 
medical  attendant  of  an  obstetrical  case.  The  navel  should  be  anti- 
septically  dressed,  and  tetanus  antitoxin  should  be  administered.  Nerve 
sedatives,  such  as  warm  baths,  bromides,  chloroform  (by  inhalation), 
chloral  (per  rectum),  belladonna,  or  even  opium,  should  be  given  in  doses 
sufficient  to  control  spasms.  If  swallowing  be  impossible,  the  food  and 
medicine  may  be  given  by  the  nasal  tube.  Every  unnecessary  disturb- 
ance, by  touch  or  sound,  should  be  avoided. 

ERYSIPELAS. 

The  streptococcus  of  erysipelas  may  find  entrance  through  the  navel, 
through  abrasions  of  the  skin,  or  through  fissures  about  the  anus.  The 
prognosis  is  especially  bad  if  the  invasion  occur  at  the  umbilicus,  as 
peritonitis  and  numerous  metastases  in  lungs,  heart,  kidney,  and  spleen 
occur. 

The  invasion  and  symptoms  are  the  same  as  in  the  adult.    The  infant 


180  DISEASES    OF    THE    NEW-BORN 

should  be  isolated  and  the  infection  combated  by  warm  antiseptic  fomen- 
tations, or  ten  per  cent,  ichthyol  ointment  over  the  affected  area,  and 
systemic  stimulation. 

ACUTE   FATTY   DEGENERATION — BUHL'S   DISEASE. 

A  rare  and  fatal  disease  of  the  new-born  infant  is  Buhl's  disease.  It 
may  develop  in  an  apparently  healthy  infant  in  whom  the  umbilicus 
shows  no  outward  sign  of  infection.  The  onset  is  gradual,  with  vomiting, 
cyanosis,  jaundice,  and  hemorrhages,  causing  inanition  and  death  within 
two  weeks.  Upon  autopsy  there  is  found  fatty  degeneration  of  liver, 
kidneys,  myocardium,  and  intestinal  villi.  The  only  treatment  is  sympto- 
matic. 

EPIDEMIC    HEMOGLOBINURIA — WINCE^l's   DISEASE. 

The  symptoms  of  Winckel's  disease  resemble  closely  those  of  acute 
fatty  degeneration,  with  the  greater  evidence  of  bacterial  origin  in  its 
contagiousness.  It  also  differs  in  the  acute  onset,  greater  tendency  to 
disintegration  of  the  red  blood-cells,  and  in  being  quickly  fatal.  Death 
follows  in  most  cases  in  less  than  forty-eight  hours. 

HEMORRHAGES. 

Hemorrhages  in  the  new-born  may  be  due  to  mechanical  causes 
during  parturition,  as  from  pressure  caused  by  vigorous  contractions 
of  the  uterus  or  compression  by  the  forceps.  The  asphyxia,  usually 
present  in  tedious  labors,  favors  the  escape  of  blood  from  atony  of  the 
vessels. 

■  The  meninges  of  the  brain  and  cord  frequently  show  rupture  of  their 
minute  vessels.  Larger  meningeal  hemorrhages  are  of  more  serious  im- 
port and  are  the  cause  of  birth  palsies.  Other  viscera  are  also  the  seat 
of  hemorrhages,  which  may  be  wholly  unsuspected  until  discovered  post- 
mortem. 

Excluding  the  hemorrhages  from  pressure  during  birth,  there  are 
occasionally  seen  cases  in  which  the  probable  cause  is  microbic  infection, 
although  the  specific  organisms  have  not  been  definitely  determined.  It 
is  well  known  that  infants  suffering  from  congenital  syphilis  are  espe- 
cially liable  to  hemorrhages  which,  as  a  capillary  oozing  from  navel,  nose, 
bowels,  and  other  organs,  are  extremely  difficult  to  control.  What  part 
in  this  hemorrhage  the  syphilitic  affection  of  the  vessels  and  deteriora- 
tion of  the  blood  plays,  and  how  much  is  due  to  other  infection,  cannot 
be  stated. 

The  local  use  of  adrenalin  solution  externally  seems  more  efficacious 
than  suturing  or  attempts  to  ligate  the  bleeding  vessels.  Mercurials,  in 
the  form  of  gray  powder  or  calomel,  should  be  given  by  mouth  in  cases 
due  to  syphilis.  Gelatin  may  be  given  by  mouth  or  rectum,  but  the 
possibility  of  tetanus  requires  careful  sterilization  if  used  hypodermically. 
Some  benefit  is  claimed  from  the  use  of  calcium  chloride. 


HEMOBRHAGBS  181 

MELENA. 

Melena,  or  hemorrhage  from  the  ^astro-intestinal  tract,  may  occur  in 
the  first  two  weeks  of  life,  rarely  later.  It  may  be  the  only  hemorrhage 
present  or  may  be  associated  with  those  from  other  tracts.  Occasionally 
numerous  minute  ulcers  in  the  stomach  and  intestines  are  seen  upon  post- 
mortem examination. 

Care  should  be  taken  in  the  diagnosis  to  exclude  blood  swallowed  dur- 
ing nursing  from  fissured  nipples. 

The  prognosis  of  melena  is  grave,  as  in  fully  one-half  the  cases  death 
ensues. 

VAGINAL    HEMORRHAGES. 

Comparatively  frequent  and  of  slight  importance,  unless  associated 
with  other  evidences  of  a  hemorrhagic  tendency,  is  a  bloody  mucous  dis- 
charge from  the  vagina  of  new-born  girls.  It  usually  ceases  by  the  third 
day  and  does  not  reappear,  excepting  in  very  rare  instances  of  precocious 
menstruation.    No  treatment  is  required. 


CHAPTER    III 
DISORDERS    OF    NUTRITION 

MARASMUS — INFANTILE  ATROPHY;     PED  ATROPHY  ;    ATHREPSIA  ;     SIMPLE 

WASTING 

Wasting  of  the  tissues,  or  general  atrophy,  is  very  common  in  the 
subacute  and  chronic  diseases  of  infancy,  especially  those  of  fatal  ter- 
mination. In  such  it  must  be  regarded  as  a  symptom  of  malnutrition, 
in  which  some  organic  cause  limits  constructive  metabolism  while  retro- 
grade tissue  metamorphosis  continues.  While  the  exact  cause  may  be 
undeterminable  during  life,  post-mortem  examination  usually  furnishes 
some  clew  to  the  etiology  of  the  morbid  process.  In  such  cases  the 
wasting  is  secondary;  but  when  no  sufficient  cause  can  be  found  by 
either  ante-  or  post-mortem  examination  the  disorder  has  been  termed 
by  common  consent  simple  atrophy,  or  marasmus. 

This  disease  has  been  placed  among  the  disorders  of  nutrition  because 
it  presents  all  the  symptoms  of  starvation.  Indeed,  it  can  be  produced 
in  the  young  infant  by  gradually  withdrawing  a  portion  of  his  daily 
food.  Strictly  speaking,  the  terms  marasmus,  infantile  atrophy,  etc., 
are  employed  as  equivalent  to  ' '  wasting  from  unknown  cause, ' '  clearly 
a  reflection  upon  the  limitations  of  our  knowledge  of  pathology  in  the 
early  stages  of  development. 

The  clinical  phenomena,  as  well  as  the  morbid  changes,  are  those  of 
starvation.  The  most  constant  lesions  of  the  digestive  tube,  such  as 
atrophy  of  the  intestinal  villi  and  tubules,  dilatation  of  the  stomach, 
thinning  of  the  gastro-intestinal  mucosa,  atrophy  of  the  lymphoid  tissue, 
and  maldevelopment  of  the  agminate  glands,  large,  fatty  liver,  small 
spleen,  and  cortical  pallor  of  the  kidneys,  with  some  parenchymatous 
degeneration,  have  all  been  the  subjects  of  animated  discussion  as  to 
their  post-  or  propter-hoc  relation  to  the  athrepsia. 

Of  the  theories  advanced  in  explanation  of  the  remarkable  wasting — 
such  as  exogenous  infection,  primary  atrophy  of  the  digestive  tract,  and 
autointoxication  from  morbid  disassimilation  products — the  last  named 
offers  a  promising  field  for  research.  The  metabolic  diatheses  of  infancy 
are  but  little  understood,  and  much  may  be  expected  in  the  near  future 
from  painstaking  study  along  this  line. 

Some  infants  are  marantic  from  birth,  at  which  time  they  are  under- 
sized and  show  feebleness  and  malnutrition.  This  is  frequently  accounted 
for  by  ill  health  of  the  mother  during  gestation  or  by  hereditary  dyscrasia 
in  which  syphilis,  tuberculosis,  alcoholism,  gout,  old  age,  and  exhausted 
vitality  figure  prominently.  Among  the  poorer  classes  unhygienic  envi- 
ronment in  the  crowded  districts  of  large  cities  furnishes  the  victims  of 
182 


MARASMUS  1  - 1 

marasmus  which  fill  the  dispensaries.  Other  disorders,  such  as  gastro- 
ciil iritis,  bronchitis,  etc.,  may  complicate  the  case,  to  any  one  of 
which  the  athrepsia  might  be  due.  The  history  is  quite  common  that 
the  infant  was  puny  and  feeble  from  birth,  and  in  the  majority  of 
instances  was  bottle-fed.  On  the  other  hand,  athrepsia  may  develop  in  a 
child  born  plump  and  vigorous,  with  a  history  of  good  health  up  to  an 
ill-advised  weaning  or  until  after  an  acute  attack  of  summer  complaint, 
bronchopneumonia,  or  one  of  the  exanthems,  after  which  no  food  seemed 
to  afford  nourishment.  Here  again  artificial  feeding  is  a  most  common 
feature  of  the  history.  In  crowded  hospital  wards  the  picture  of  maras- 
mus is  familiar,  and  the  tendency  of  well-nourished  infants,  admitted 
for  acute  disorders,  to  become  marantic  during  convalescence  is  so  gener- 
ally recognized  as  to  raise  the  question  of  the  wisdom  of  long  residence 
and  of  large  aggregations  in  one  hospital.  The  frequency  and  intracta- 
bility of  athrepsia  in  crowded  wards  lends  color  to  the  claim  that 
exogenous  infection  is  an  important  etiologic  factor. 

Symptoms. — Although  the  cause  may  be  unknown,  the  picture  is 
typical  of  a  vicious  circle  in  which  all  the  physiologic  functions  show 
reactionary  impairment  until  nutrition,  oxidation,  and  vitality  are  re- 
duced to  the  lowest  point.  Emaciation  is  extreme.  All  the  fat  dis- 
appears except  the  sucking  pads.  The  voluntary  muscles  are  reduced 
to  mere  strings  over  wThich  the  wrinkled  skin  hangs  in  folds.  The  fon- 
tanelle  is  depressed,  the  face  is  drawn  and  wrinkled,  giving  the  appear- 
ance of  senility,  which  is  intensified  by  the  hollow  temples,  sunken 
eyes,  thin  lips,  and  toothless  gums.  The  skeletal  structures  show  dis- 
tinctly beneath  the  skin.  The  rectal  temperature  is  rarely  above  normal, 
and  may  be  one  or  two  degrees  below,  while  the  extremities  and  super- 
ficies are  usually  quite  cold.  The  respiration  is  shallow,  the  pulse  weak 
and  irregular,  and  the  cry,  at  first  fretful,  becomes  a  feeble  whine  until 
silenced  in  exhaustion.  The  common  symptom,  hunger,  is  evinced  by 
constant  sucking  of  the  claw-like  fingers,  the  anxious,  watchful  expres- 
sion, and  the  avidity  with  which  the  child  takes  everything  offered  in 
the  form  of  food.  The  hunger  is  never  satisfied  until  the  apathy  of 
exhaustion  supervenes,  after  which  bare  life  may  be  prolonged  in  a  semi- 
vegetative  state  when  for  days  or  weeks  death  seems  imminent  (Fig.  109). 

The  symptoms  vary  as  intercurrent  disorders  develop, — such  as  in- 
toxication fever,  bronchopneumonia,  vomiting,  and  diarrhoea  from  gastro- 
intestinal indigestion,  etc.  Various  skin  lesions,  such  as  furunculosis, 
intertrigo,  ecchymoses,  and  bed-sores  are  common. 

Anremia  is  marked,  though  corpuscular  loss  may  not  be  so  apparent 
on  account  of  blood  concentration.  (Edema,  especially  of  the  feet  and 
legs,  may  occur  as  a  late  sign,  but  effusion  into  the  cavities  is  rarely 
reported. 

The  abdomen  may  be  flat  from  atrophy  of  intestinal  and  mesenteric 
tissues,  or  distended  with  flatus.  The  stools  may  be  normal  or  show  any 
of  the  varieties  of  indigestion  or  constipation. 

Cervical  rigidity  and  pseudomeningeal  symptoms  with  twitchings  and 


184 


DISORDERS    OF    NUTRITION 


convulsions  are  not  uncommon  in  the  later  stage,  or  the  long-expected 
death  may  occur  suddenly,  without  immediate  premonitory  symptoms. 

Prognosis. — The  prognosis  in  marasmus  is  so  dependent  upon  the  pri- 
mary cause — the  degree,  the  environment,  and  the  treatment — that  it  must 
be  guarded  until  after  a  thorough  study  of  all  the  factors  which  enter  into 
this  condition.  Pedatrophy  is  extremely  intractable,  and  one  of  the  most 
fatal  disorders  of  infancy. 

Diagnosis. — Simple  infantile  atrophy  is  too  often  the  diagnosis  in 
cases  where  a  more  careful  study  would  reveal  the  true  cause  of  the 

athrepsia.  Repeated  examination  of 
the  mother's  milk  may  show  a  defi- 
ciency in  quantity  or  quality.  The 
child  may  not  nurse  well  because  of 
painful  stomatitis,  congenital  defects 
of  palate,  obstruction  to  respira- 
tion, or  defective  nipple.  Ignorance 
or  carelessness  in  the  hygiene  of 
early  lactation  may  easily  start  the 
vicious  circle  in  feeble  infants. 
Masked  forms  of  dyspepsia  may  in- 
augurate the  morbid  process,  espe- 
cially in  bottle-fed  babies.  Congen- 
ital syphilis  rarely  fails  to  furnish 
some  specific  symptoms  other  than 
the  athrepsia.  From  tuberculosis  the 
diagnosis  of  pedatrophy  is  sometimes 
impossible.  The  evening  rise  in 
temperature  in  the  former  and  the 
usual  subnormal  temperature  of  the 
latter  should  be  kept  in  mind,  though 
complications  may  give  rise  to  fever 
in  pedatrophy.  The  pulmonary  hy- 
postasis of  maransis  must  not  be 
confounded  with  tubercular  lesions, 
which  may  give  rise  to  signs  in 
the  anterior  and  upper  chest,  while  the  former  always  occupies  a  strip 
of  the  posterior  and  inner  borders  of  the  lungs.  Tabes  mesenterica  and 
abdominal  tuberculosis,  in  addition  to  the  fever,  may  show  ascites  or 
enlarged  masses  in  the  mesentery. 

Meningitis  should  give  exaggerated  reflexes  and  other  symptoms  be- 
sides the  frequent  characteristic  eye  findings  of  that  disease. 

Treatment. — No  specific  medication  is  known  for  simple  atrophy. 
Good  hygiene  is  all-essential.  The  food  must  be  adjusted,  if  possible, 
to  the  digestive  capacity  of  the  individual.  Most  of  these  cases  are 
aggravated  by  high  proteids  and  fats  which  probably  increase  auto- 
intoxication from  their  disassimulation  products  with  reduction  of  alka- 
linity of  the  body  fluids. 


Fig.    110.— Infantile  atrophy.     Age,   1   year; 
weight,  ten  and  one-half  pounds. 


RIIACHITIS  185 

Pats  should  be  reduced  to  the  minimum,  proteids  cut  down  to  the 
lowest  point;  carbohydrates  should  be  increased,  and  alkalies  supplied 
with  the  food  and  by  enteroelysis. 

This  rule  is  only  general,  as  each  case  must  furnish  the  basis  of  its 
own  treatment.  Breast  milk  for  young  infants  must  be  secured,  if  pos- 
sible, though  it  may  be  necessary  to  limit  the  amount  and  to  supplement 
the  feeding  with  milk-sugar  solution,  cereal  gruels,  and  sodium  bicar- 
bonate, or  lime-water.  The  vegetable  acids  in  orange-  and  grape- juice 
may  prove  valuable,  so,  also,  daily  massage  with  olive  oil  or  emulsions 
of  mixed  oils  and  fats. 

Cleanliness,  fresh  air,  and  sunshine  are  essential,  to  secure  which 
it  may  be  necessary  to  remove  the  child  from  crowded  hospital  and 
home  environment.  A  change  of  climate  is  often  productive  of  the 
greatest  benefit. 

RHACHITIS. 

Rickets  is  the  most  prevalent  among  the  infantile  disorders  of  nutri- 
tion,— for  such  it  must  be  classed  until  a  more  exact  knowledge  of  its 
true  nature  is  obtained.  Of  the  many  theories  which  have  been  advanced 
concerning  its  causation  a  few  are  still  advocated,  such  as  insufficient 
amount  of  calcium  salts  in  the  blood ;  imperfect  absorption  of  these  salts 
from  the  intestine ;  deficiency  of  earthy  salts  in  the  food ;  diminished 
deposition  of  these  salts  from  subalkalinity  of  the  blood;  rapid  dis- 
solution of  salts  by  an  acid  in  the  body  fluids;  also,  that  the  disease  is 
an  exogenous  infection,  that  it  is  due  to  autoinfection,  and  that  the  bone 
changes  are  inflammatory  in  character.  It  is  the  consensus  of  opinion,  how- 
ever, that  its  true  etiology  is  yet  to  be  discovered,  or  that  a  combination 
of  causes,  including  some  of  the  above,  is  responsible.  The  predisposing 
causes  are  pretty  well  understood  as  residing  in  malhygiene,  especially 
in  bad  air,  improper  food,  and  absence  of  sunlight.  Every  physician  is 
satisfied  that  a  combination  of  these  influences  can  produce  the  disease, 
though  he  may  not  always  predict  with  certainty  whether  the  mal- 
hygiene will  result  in  rickets,  scorbutus,  or  marasmus. 

That  rickets  is  on  the  increase  is  probable,  but  that  its  symptoms  are 
better  known  and  earlier  recognized  is  equally  true,  and  its  wide  preva- 
lence generally  acknowledged.  No  class  is  exempt,  since  some  of  the 
above-mentioned  elements  of  malhygiene  obtain  in  the  homes  of  the 
wealthy  as  wrell  as  among  the  poor;  but  it  is  from  the  latter  that  the 
ranks  of  the  rhachitic  which  swarm  our  dispensaries  are  recruited.  As 
before  stated,  it  is  a  disease  of  the  temperate  zone,  to  which  Europeans 
and  Americans  show  the  greatest  susceptibility,  and  is  most  commonly 
seen  in  its  exaggerated  form  in  this  country  among  children  of  Southern 
people  who  have  taken  residence  in  the  colder,  changeable  Northern  cli- 
mate. Thus,  negroes  and  Italians  furnish  the  most  familiar  examples. 
Rickets  is  rarely  seen  in  a  country  infant  fed  at  the  breast.  The 
few  exceptions  are  among  those  who  have  been  nursed  long  overtime, 
whose  mothers  are  exhausted  by  overwork,  prolonged  lactation,  and 
frequent  childbearing,  and  among  the  products  of  later  conceptions  in 


186  DISORDERS    OF    XUTRITIOX 

families  whose  older  children  may  give  no  evidence  of  the  disease. 
In  cities,  though  the  proportion  is  small  in  the  breast-fed,  its  occurrence 
is  not  rare.  Breast  milk,  poor  in  fats  and  proteids,  may  apparently 
produce  the  disease,  since  the  rhachitic  symptoms  disappear  when  these 
constituents  are  increased  by  improved  hygiene  of  the  mother  or  im- 
proved supplemental  feeding  of  the  baby.  That  prerhachitic  digestive 
disturbances  are  very  common  has  led  many  to  adopt  the  theory  of  auto- 
intoxication as  the  true  etiologic  explanation.  By  others  indigestion  is 
regarded  as  one  of  the  usual  manifestations  of  the  dyscrasia. 

The  great  majority  of  rhachitic  infants  are  found  among  those  de- 
prived of  breast  milk,  especially  those  whose  diet  is  deficient  in  fat  and 
proteids.  Many  infant  foods  on  the  market  show  a  paucity  of  these 
two  ingredients, — especially  of  fat  with  a  corresponding  excess  of  starchy 
and  saccharine  constituents.  Among  the  effects  of  their  ingestion  is 
early  rapid  gain  in  weight  and  rotundity  from  large  deposits  of  fat,  but 
the  tissues  are  soft  and  flabby,  and  indigestion  usually  precedes,  but  may 
accompany  or  follow  the  development  of  rickets. 

It  is  generally  accepted  that  the  increase  in  the  frequency  of  rhachitis 
is  in  direct  ratio  with  the  prevalence  of  artificial  feeding,  especially  with 
foods  consisting  largely  of  carbohydrates  with  a  scarcity  of  nitrogenous 
elements.     (See  chapter  on  Foods.) 

There  is  little  or  no  evidence  of  heredity  in  the  causation  of  rickets 
further  than  that  low  vitality  and  vitiated  metabolism  predispose  to 
rhachitic  changes.  In  this  way  syphilis,  tuberculosis,  and  alcoholism 
undoubtedly  exert  a  predisposing  influence. 

Rhachitic  changes  are  usually  seen  between  the  sixth  and  twenty- 
fourth  months,  most  noticeably  in  the  second  year.  Though  symptoms 
may  appear  earlier,  rarely  a  congenital  case  is  reported  (Fig.  111).  Many 
cases  of  so-called  fetal  rickets  present  changes  not  characteristic  of  this 
disease  and  belong  rather  to  achondroplasia  (Chondrodystrophy  fetalis) 
and  cretinism.  Late  rickets  described  by  European  writers  as  occurring 
about  the  age  of  puberty  are  certainly  not  frequent  in  this  country, 
where  the  inception  is  rarely  seen  after  the  third  year.  So,  also,  reported 
cases  of  acute  rickets,  if  carefully  analyzed,  often  prove  to  be  either  a 
rapid  development,  under  conditions  which  caused  sudden  lowering  of 
vitality,  or  rhachitic  changes  which  had  previously  passed  unobserved, 
or  cases  of  scorbutus  with  which  rhachitis  is  not  infrequently  complicated. 

Pathology. — Probably  no  organ  or  tissue  in  the  body  is  exempt  from 
the  morbidity  of  severe  rickets,  although  the  only  changes  pathognomonic 
of  the  disease  as  at  present  recognized  are  seen  in  the  bones.  For  clinical 
purposes  it  is  sufficient  to  state  that  the  bones  show  a  deficiency  of  inor- 
ganic material  ( principally  of  the  lime  salts)  which  in  normal  bone  con- 
stitutes two-thirds,  while  one-third  is  organic  matter.  (See  chapter  on 
Anatomy.;  In  rhachitis  this  ratio  may  be  reversed.  Because  of  in- 
creased vascularity  at  the  proliferative  zones,  retarded  calcification  at 
thfj  epiphyses  and  alone  the  shafts,  and  increased  bone  absorption  in  the 
medullary  cavities  (Fig.  112;  the  entire  bone  becomes  light,  spongy,  and 


RIIAUHITIS 


187 


plastic,  bends  readily  under  superimposed  weight,  strain  of  muscles  or 
malposition,  and  fractures  (green-stick)  occur  from  slighl  violence.  The 
increased  vascularity  in  the  growth  zones  causes  active  proliferation  of 
cartilage  cells  which,  with  the  retarded  ossification,  results  in  an  accumu- 
lation of  osteoid  material  in  these  areas  with  rapid  increase  in  size  of  the 
epiphyses.  Or  it  may  cause  doughy  accumulations  over  the  ossific 
centres  of  the  cranial  bones  which,  while  thickened  in  some  spots,  may 
be  thinned  in  others, — notably  where  subject  to  pressure,  as  in  the  occipi- 
tal bone  of  the  skull.     These  enlargements  are  most  pronounced  in  the 


^ 


■< 


Fig.  111.— Fetal  rickets. 


Fig.  112.— Rhachitic  bone. 


epiphyses  subject  to  the  greatest  motion  from  the  stimulation  due  to 
increased  blood-supply.  From  their  constant  movement  in  respiration 
these  enlargements  are  first  seen  at  the  anterior  ends  of  the  ribs,  of 
which  the  sixth  is  most  notably  affected  from  its  greater  range  of  move- 
ment. In  young  infants  the  epiphyses  of  the  forearms  show  early  swell- 
ing above  the  active  wrist  joints,  while  in  children  who  have  begun  to 
walk,  the  lower  ends  of  the  tibia*  show  early  changes.  After  a  period 
varying  from  three  to  twenty  months  the  rhachitic  process  is  arrested, 
true  ossification  is  resumed,  much  of  the  osteoid  material  is  absorbed,  and 


188  DISORDERS    OF    NUTRITION 

eburnation  occurs,  the  newly  formed  bone  becoming  harder  than  normal. 
The  enlargement  of  the  epiphyses  may  disappear,  but  if  the  degree  of 
rickets  has  been  severe  or  prolonged,  some  permanent  effects  will  remain 
in  deformities  and  retardation  of  .longitudinal  growth. 

These  deformities  are  particularly  noticeable  in  the  chest,  which 
assumes  characteristic  shapes  influenced  more  or  less  by  the  condition 
of  its  contained  viscera  during  the  period  of  greatest  plasticity.  Pro- 
longed dorsal  decubitus  causes  flattening  of  the  back  and  of  the  posterior 
curvature  of  the  ribs,  with  pushing  forward  of  the  anterior  ends,  and 
advancement  of  the  sternum.  If  pulmonary  atelectasis  or  obstruction 
to  free  entrance  of  air  obtain  from  adenoids,  rhinitis,  or  complicating 
pulmonopathy,  external  atmospheric  pressure  opposing  the  pull  of  the 
inspiratory  muscles  causes  a  flattening  of  the  chest  at  its  most  yielding 
points.  These  are  the  anterior  lateral  parietes  just  above  the  line  of  resist- 
ance offered  to  depression  by  the  subjacent  liver,  spleen  and  stomach, 
where  a  permanent  sulcus  is  commonly  seen  (Harrison's  groove).  The 
lines  of  greatest  mobility  may  show  a  groove  along  the  costocartilaginous 
junction  on  either  side  of  and  parallel  with  the  sternum,  in  which  case 
the  breast-bone  is  pushed  forward  like  a  prow  (pigeon-breast).  Under 
pressure  the  ends  of  the  ribs  may  knuckle,  causing  depressed  or  funnel- 
shaped  sternum.  The  lower  margin  of  the  ribs  usually  flares  outward 
owing  to  the  contracted  chest,  the  enlarged  abdomen,  and  the  pull  of 
the  accessory  muscles  of  inspiration.  The  permanent  changes  in  the 
cranial  bones  are  seen  in  the  parietal  and  frontal  bossse  which,  with  the 
flattened  vertex  and  occiput,  give  the  cuboid  head.  The  maxilla?  show 
the  effects  of  rhachitis  in  that  the  lower  face  appears  small  in  comparison 
with  the  broad  expanse  of  forehead.  The  superior  maxilla  may  be  nar- 
rowed and  elongated  with  high-arching  palate,  while  the  inferior  is 
polygonal  with  flaring  lower  borders  and  an  inward  inclination  of  the 
alveoli  which  allows  later  overriding  of  the  upper  jaw.  Dentition  is 
delayed,  the  teeth  erupting  irregularly  and  showing  early  erosion  from 
deficient  enamel  and  lack  of  calcium  salts.  Later  they  may  be  crowded 
and  irregular  in  their  implantation  owing  to  abnormal  contour  of  the 
jaws. 

Deformities  of  the  extremities  are  seen  in  curvatures  from  weight* 
muscle-tug,  and  infractions  causing  bow-legs,  knock-knees,  twisted  and 
anterior  curved  tibiae,  with  curvatures  of  the  femora  humeri,  clavicles, 
and  scapula?. 

The  pelvis  may  be  distorted  by  the  yielding  of  the  ischii  from  sitting. 
The  sacrum  may  be  forced  downward  and  forward  from  its  superincum- 
bent weight  while  sitting  or  standing,  causing  shortening  of  its  antero- 
posterior diameter.  A  general  contraction  may  result  from  tightly  con- 
stricting diapers  during  the  plastic  stage  (Fig.  113).  a  condition  which 
in  girls  is  of  the  gravest  import  with  reference  to  future  parturition. 
Characteristic  of  the  rhachitic  state  is  laxity  of  ligaments  which,  yield- 
ing, allow  deformities,  such  as  flat-foot,  talipes  varus  and  valgus,  genu 
varum  and  valgum,  which  are  accentuated  by  the  curving  or  infrac- 


RIIACIIITLS 


189 


tions  of  the  leg  and  thigh  bones.  The  vertebral  ligaments,  also  stretching, 
allow  kyphotic  and  rotary  distortions  of  the  spinal  column,  while  all  the 
articulations  show  undue  mobility  (Figs.  113  to  11");. 

The  muscular  system  is  atonic,  so  that  support  to  the  trunk  is  de- 
fective and  permits  the  spinal  distortion  above  mentioned  when  the  child 
assumes  the  vertical  position.  Atony  allows  distention  of  the  stomach 
and  bowels  with  constipation,  meteorism,  and  enlarged  abdomen,  while 
hernia,  especially  umbilical,  prolapsus  ani,  and  intussusception  of  the 
bowel  are  consequent  conditions.  Weakness  of  the  leg  muscles  causes 
backwardness  in  learning  to  walk,  or,  having  been  acquired,  the  function 
is  lost.    The  child  may  not  be  able  even  to  sit  without  support. 


Figs.  113  and  111.— Rhachitic  curvature  of  spine.    (Rush  Medical  Museum.) 

The  mucous  membranes  show  a  predilection  to  catarrh,  especially  of 
the  respiratory  tract.  Owing  to  yielding  thoracic  walls  and  feeble  mus- 
cles this  favors  bronchitis,  bronchopneumonia,  atelectasis,  emphysema, 
and  hypostatic  congestion, — all  of  which  intensifies  the  vicious  circle  by 
interference  with  oxygenation  from  respiratory  inefficiency. 

The  nervous  system  shows  instability  by  profuse  head  sweating,  dis- 
turbed sleep,  kicking  off  the  bedclothes,  night  terrors,  hyperesthesia,  and 
pain  on  handling  (which  may  also  be  due  to  tenderness  of  the  enlarged 
epiphyses),  easily  induced  spasm  of  the  glottis  (laryngismus  stridulus), 
and  convulsions  (tetany).  There  is  general  irritability,  fretfulness,  and 
hyperexcitability, — a  condition  not  uncommon  in  poorly  nourished 
nerve-tissues  from  any  cause. 


190 


DISORDERS    OF    NUTRITION 


The  profuse  sweating  leads  to  sudamina  and  eczema,  and  induces 
catarrh  of  the  upper  respiratory  tract  from  "cold  catching."  Various 
skin  eruptions  result  from  the  faulty  metabolism  and  toxic  products 
of  indigestion.  The  lymph-nodes  may  show  enlargement  as  the  result  of 
neighboring  lesions  of  skin  or  mucosa,  and  the  obsolete  term,  "scrofula," 
has  frequently  been  misapplied  to  cases  now  recognized  as  rhachitic. 
The  cushiony  pad  on  the  dorsum  of  the  foot  is  not  rare  in  infant  rickets 
and  suggests  angioneurotic  oedema,  although  there  is  no  pitting  on 
pressure. 

The  spleen  is  palpable  in  a  fair  proportion  of  cases  and  occasionally 


Fig.  115.— Rhachitic  deformities.       Fig.  116.— Rhachitic  family,  breast-fed  ;  later  diet  chiefly  bread 
(Dr.  John  C.  Cook. )  and  molasses  ;  lived  in  basement.     (Dr.  John  C.  Cook.) 

it  is  enormously  enlarged,  so  also  the  area  of  hepatic  dulness  may  be 
considerably  increased,  although  the  prominence  of  both  these  organs  is 
due  in  part  to  their  being  crowded  down  by  the  contraction  of  the  chest. 

The  blood  shows  no  constant  or  characteristic  changes  in  rickets  save 
that  of  secondary  anaemia  which,  in  severe  or  prolonged  cases,  may  be- 
come extreme.  In  this  case  the  only  peculiarity  is  its  low  color  index 
and  a  lymphocytosis,  which  some  observers  have  associated  with  the 
marked  enlargement  of  the  spleen. 

Symptoms. — The  visible  lesions  and  their  immediate  effects  constitute 


RHACHITIS 


101 


the  chief  symptoms  of  marked  rhachitis.  Clinically  they  arrange  them- 
selves into  three  groups, — viz.,  nervous,  muscular  and  osseous, — to 
which  may  he  added  dyspeptic  and  catarrhal.  A  plump  baby  be- 
comes irritable  and  weak,  has  head-sweating,  night-kicking,  with  or 
without  apparent  indigestion.  Teething  is  delayed,  walking  is  delayed 
or  discontinued,  the  tissues  become  flabby,  the  child  docs  not  sit  up  well, 
nor  stand,  the  spine  curves  backwards,  the  fontanelle  is  wide,  the  hair 
is  worn  off  the  occiput,  the  child  cries  when  handled,  and  becomes  fret- 
ful. He  may  show  breath-holding,  crowing  inspiration,  or  a  peculiar 
clucking  in  his  throat.  The  physician  may  be  consulted  for  convulsions 
(see  Tetany),  for  paralysis  (pseudorhachitic),  for  diarrhoea,  or  constipa- 


Fig.  117.— Rhachitic  deformities. 
(Dr.  John  C.  Cook.) 


Fig.  118.— Rhachitis. 


tion,  when  the  foregoing  history  is  obtained.  Examination,  even  in  the 
early  stage,  rarely  fails  to  find  the  ' '  rhachitic  rosary ' '  which,  in  fat 
babies,  may  be  felt  if  not  seen  following  the  diverging  lines  of  the  costo- 
cartilaginous  junctions.  Possibly  only  one  enlargement  may  be  de- 
tected— the  sixth — but  one  is  sufficient.  The  head  may  begin  to  assume 
cuboidal  shape  from  frontal  and  parietal  bossa?,  and  pressure  with  the 
finger  over  the  occipital  bone  may  find  yielding  spots  (craniotabes). 
Later,  the  epiphyses  show  enlargements,  especially  those  of  the  ulna  and 
radius  at  the  wrists,  or  of  the  malleoli  above  the  ankles.  In  all  cases  the 
enlargements  are  bilateral  and  symmetrical.  The  later  and  more  ob- 
vious bony  signs  of  rickets  appear  as  bow-legs,  knock-knees,  talipes,  in- 


192 


DISORDERS    OF    NUTRITION 


fractions,  and  bizarre  deformities  (Figs.  113  to  120  inclusive),  which 
come  properly  under  the  subject  of  orthopaedics. 

Prognosis. — Children  rarely  die  of  rhachitis  per  se.  It  is  usually  some 
concomitant  or  intercurrent  disorder  that  terminates  life.  Of  these  the 
pulmonopathies  find  in  the  rhachitic  child  most  favorable  conditions 
which,  if  survived,  leave  the  patient  with  permanently  damaged  chest 
and  respiratory  organs, — a  standing  invitation  to  tubercular  infection. 

The  active  rhachitic  processes  cease  or  begin  to  diminish  before  the 
end  of  the  second  year,  although  occasionally  porosity  and  fragility  of  the 
bones  may  continue  for  some  time  later.    The  minor  defects  are  remedied 


Fig.  119. 


-Skiagram  of  genu  valgum.  (Dr.  Wallace 
Blanchard.) 


Fig.  120.— Skiagram  of  bow-legs.   (Dr.  Wallace 
Blanchard.) 


to  a  remarkable  degree,  but  a  register  of  the  disease  remains  in  the  major 
deformities  of  chest,  head,  and  face,  which  are  carried  into  adult  life. 
The  legs  may  remain  short  and  the  long  bones  more  or  less  curved, 
so  that  in  extreme  cases  osteoplastic  surgery  must  be  invoked  for  restora- 
tion of  their  normal  function. 

Diagnosis. — The  picture  of  marked  rhachitis  is  unmistakable.  It  is 
only  in  its  incipiency  and  some  of  its  rare  late  manifestations  that  its 
recognition  is  difficult.  Moreover,  its  early  diagnosis  is  of  the  highest 
importance  since  it  is  here  that  its  correction  is  most  easily  effected  and 


RHACHITIS  193 

its  far-reaching  results  averted.  I  lend  sweating,  night  restlessness,  with 
kicking  off  the  bedclothes  (unless  unduly  burdened),  delayed  dentition, 
late  closure  of  the  fontanelles,  delayed  standing  and  walking,  weak 
back,  slight  enlargement  of  the  epiphyses,  beading  of  the  ribs — which 
must  always  be  felt  for — and  prominent  abdomen,  should  be  taken  as 
evidences  of  rhachitis,  regardless  of  the  avidity  for  food  or  appearance 
of  fatness,  too  often  considered  as  evidence  of  good  health. 

It  should  be  remembered  that  marasmus  may  exist  to  an  extreme 
degree  without  the  faintest  suggestion  of  rickets. 

The  large  head  may  be  mistaken  for  hydrocephalus,  but  the  internal 
pressure  in  the  latter  causes  a  more  symmetrical  bulging  than  do  the 
bossas  of  rickets.  The  large,  globular  head,  with  bulging  fontanelle,  tiny 
face,  and  deflected  visual  axes,  are  not  often  seen  in  rickets,  but  it  is 
possible  for  the  two  conditions  to  exist  in  the  same  child. 

The  pseuclorhachitic  paralysis  must  be  distinguished  from  essential 
paralysis  which  it  resembles  only  in  locomotor  incapacity.  The  muscles, 
although  weak,  will  move  the  limbs  in  response  to  reflex  irritation, 
as  may  be  seen  by  tickling  the  soles  of  the  feet.  If  the  muscular  atony 
be  extreme  it  involves  the  entire  system  and  is  not  confined  to  particular 
groups  of  muscles,  as  in  paralysis.  Moreover,  other  evidences  of  rhachitis 
are  present.  However,  a  rhachitic  child  is  not  immune  to  essential 
paralyses  and  muscular  dystrophies,  which  may  at  any  time  supervene. 

Scorbutus  may  complicate  rhachitis — in  fact,  a  form  has  been  recog- 
nized as  ' '  scurvy-rickets ' ' — but  the  two  disorders  need  never  be  con- 
founded, as  each  has  its  peculiar  semeiology  and  pathology  (q.  v.),  while 
the  former  yields  promptly  to  antiscorbutic  treatment. 

Syphilitic  bony  enlargements  will  not  be  mistaken  for  rhachitis  if  it 
be  remembered  that  the  latter  always  involves  the  epiphyses  of  the  long 
bone,  is  symmetrical  and  never  breaks  down  to  form  sinuses;  while 
syphilis,  in  its  earlier  stage,  shows  enlargement  at  the  epiphyseal  junc- 
ture, is  rarely  bilateral,  is  boggy  to  the  feel  and  tender,  and  tends  to 
necrosis  and  abscess  formation.  In  later  stages  it  is  the  shaft  over  which 
thickening  occurs.  Rhachitic  kyphosis  and  kyphoscoliosis  is  distinguished 
from  tuberculosis  spondylitis  by  the  convexity  of  the  deviation  in  place 
of  the  angular  deformity  of  the  latter,  and  by  the  absence  of  spinal 
rigidity  in  the  early  stages,  which  may  be  shown  by  suspending  the  child 
from  the  arm  pits,  whereupon  the  kyphosis  disappears  ;  or  by  raising  the 
child  by  the  feet  while  he  lies  face  downwards,  and  noting  the  flexibility 
of  the  dorsal  spine. 

Treatment. — Since  there  is  no  known  specific  for  rhachitis  the  treat- 
ment, from  our  knowledge  of  the  etiology,  must  be  hygienic.  The  diet 
must  be  suitable  to  age  and  the  condition  of  the  digestive  function  of  the 
individual  infant. 

The  paucity  of  fat  and  proteids  and  the  excess  of  carbohydrates 
usually  seen  in  prerhachitic  diet,  as  well  as  the  prevalence  of  dyspepsia, 
suggest  the  key  to  the  method  of  feeding.  Fat  from  cream,  fried  bacon, 
boiled  beef-bone  marrow,  and  cod-liver  oil  are  accessible  and  should  be 

13 


194 


DISORDERS    OF    NUTRITION 


given  as  the  stomach  will  allow,  preferably  with  or  just  after  other  food, 
which  should  contain  proteids  up  to  the  point  of  toleration.  At  this 
age  milk  should  form  the  basis  of  the  food.  If  at  the  breast,  repeated 
analyses  of  the  mother's  milk  should  determine  its  quality  (see  Milk 
Analysis),  and  efforts  should  be  made  to  improve  its  defects  by  attention 
to  the  mother's  hygiene.  In  obstinate  cases  supplemental  feeding  may 
be  necessary,  although  rarely  weaning  unless  the  breast  fails  from  pro- 
longed lactation  or  other  causes.  In  artificial  feeding  raw  milk  is  to  be 
preferred,  and  some  raw  fruit  juice,  especially  that  of  orange  or  grape, 
should  be  given  two  or  three  times  daily.  Excess  of  sugar  must  be 
avoided.  A  limited  amount  of  cereal  gruels  as  diluents  of  the  milk  mix- 
ture is  frequently  useful;    and  digestive  ferments,  as  pepsin  and  pan- 


Fig.  121.— Rhachitic  deformities.    (Dr.  Wallace 
Blanchard.) 


Fig.  122.— Same  as  Fig.  121,  after  correction. 
(Dr.  Wallace  Blanchard.) 


creatin,  may  serve  a  temporary  purpose,  but  should  never  be  long  con- 
tinued. Lime-water,  unless  constipation  be  marked,  sodium  bicarbon- 
ate or  sodium  citrate,  and  always  some  common  salt,  should  enter  into 
every  meal. 

The  general  hygiene  requires  careful  attention.  Fresh  air  and  sun- 
light are  essential,  and  bathing,  with  salt  friction,  must  be  enforced.  A 
rhachitic  child  must  never  be  subjected  to  cold  bathing  until  after  com- 
plete recovery.  Change  of  climate  may  be  necessary  to  secure  the  re- 
quisite hygiene. 

Intercurrent  and  complicating  disorders  must  be  met  by  appropriate 
treatment.     The  routine  practice  of  giving  phosphorus,  phosphates,  and 


RHACHITIS 


195 


hypophosphites  medically  is  of  questionable  utility,  especially  if  it  in 
any  degree  divert  attention  from  the  proper  feeding  and  care  of  the 
baby.  The  lime  phosphate  should  be  secured  from  the  food  of  which 
breast  milk  furnishes  the  highest  percentages  available.  The  anaemia 
may  need  iron  and  arsenic. 

While  the  bones  are  soft,  deformities  may  be  prevented  by  keeping  the 
child  off  his  feet,  employing  daily  massage  with  oil  to  promote  metab- 
olism. The  temporary  use  of  retention  splints  and  braces  may  be  ser- 
viceable during  the  plastic  stage  to  preserve  alignment  of  the  articula- 


Fig.  123.— Rhachitic  bow-legs.     (Dr.  Wallace 
Blanchard.) 


Fig.  124. — Same  as  Fig.  123,  after  correction. 
(Dr.  Wallace  Blanchard. ) 


tions  for  which  the  lax  ligaments  and  weak  muscles  are  insufficient,  but 
efforts  to  correct  established  deformities  by  such  means  are  frequently 
disappointing.  Post-rhachitic  deformities  of  the  trunk  and  extremities 
demand  the  skill  of  orthopaedic  surgery,  the  brilliant  results  of  which 
speak  for  themselves  (Figs.  121  to  126). 


SCORBUTUS — INFANTILE   SCURVY. 

In  no  disorder  is  mismanagement  in  the  diet  more  apparent  than  in 
scurvy.     Although  infantile  scurvy  was  unrecognized  thirty  years  ago, 


196 


DISORDERS    OF    NUTKITIOX 


to-day  its  clinical  entity  is  so  well  established  as  to  become  a  familiar 
picture  to  all  who  practise  among  children.  There  is  little  doubt,  since 
the  early  descriptions  of  Cheadle  and  Barlow,  that  the  occurrence  of  scor- 
butus has  been  steadily  on  the  increase.  Nor  is  this  difficult  of  explana- 
tion, as  our  present  knowledge  of  its  etiology  places  the  responsibility 
upon  certain  errors  in  infant  diet  which  are  known  to  prevail  with 
steadily  increasing  frequency. 

The  fashion  or  frailty  which  deprives  the  infant  of  normal  breast 


Fig.  125. 


-Rhachitic  knock-knees.     (Dr.  Wallace 
Blanchard.j 


Fig.  126. — Same  as  Fig.  125,  after  correction. 
(Dr.  Wallace  Blanchard.) 


milk  is  undoubtedly  the  most  responsible  factor  in  the  etiology.  The 
fad  or  actual  necessity  for  sterilization  of  infant  foods  is  another.  The 
claim  that  malhygienic  environment  is  a  potent  factor  is  not  substan- 
tiated by  analysis  of  three  hundred  and  seventy-nine  reported  cases,  of 
which  eighty-seven  per  cent,  were  observed  in  private  practice.  Whether 
the  disease  is  caused  by  a  hyperacidity  or  a  subalkalinity  of  the  blood 
from  a  deficiency  of  organic  salts,  especially  of  potash,  by  ptomaine- 


SCORBUTUS  197 

poisoning  from  imperfect  digestion,  or  is  due  to  infection  of  microbic 
nature,  the  fact  has  been  amply  demonstrated  that  a  proper  change  in 
the  dietary  effects  a  prompt  relief  of  all  the  symptoms.  The  disease 
is  most  commonly  seen  between  the  fifth  and  eighteenth  months,  although 
it  has  been  found  in  earlier  infancy  and  older  children. 

The  essential  manifestations  are  due  to  hemorrhages  into  the  various 
organs  and  tissues.  The  most  common  sites  and  those  producing  the 
most  characteristic  lesions  are  in  the  periosteal  structures  of  the  long 
bones  and  the  mucosa  of  the  mouth,  particularly  the  gums  and  hard 
palate.  The  skin,  also,  frequently  shows  purpuric  lesions  as  petechia? 
and  ecchymoses.  Epistaxis  is  not  infrequent,  and  blood  occasionally  ap- 
pears in  the  stools  and  urine.  Extravasations  of  blood  may  occur  under 
the  serous  membranes,  as  the  pleura?,  pericardium,  or  meninges  of  the 
brain;  also,  in  the  deep  muscular  structures  as  well  as  in  the  medulla 
of  the  bones.  The  bones  themselves  show  changes  principally  character- 
istic of  rickets,  with  which  this  condition  is  frequently  associated.  It 
differs  from  rickets,  however,  in  its  predisposition  to  hemorrhages.  The 
epiphysis  may  be  separated  from  the  shaft  and  dislocated  by  the  amount 
of  extravasation.  This  may  extend  through  the  cellular  tissue  to  the 
neighborhood  of  the  articulations,  although  rarely  into  the  joint  cavity. 
The  blood  itself  shows  no  changes  except  those  common  to  a  simple,  sec- 
ondary anaemia. 

The  onset  is  insidious.  The  frequent  association  of  rhachitis  and 
the  gastro-enteric  disturbances,  common  to  this  age,  mask  the  earlier 
symptoms  of  scorbutus.  A  routine  examination  of  the  urine  may 
give  the  first  intimation  of  its  existence  in  the  discovery  of  a  slight 
hematuria;  or  the  mother  may  discover  that  the  fretfulness  of  the 
baby  on  handling  is  due  to  tenderness  of  the  chest  or  limbs.  When 
seen  at  this  stage,  in  the  absence  of  complications,  the  baby  may  appear 
plump  and  well  nourished  but  is  usually  pale.  Examination  shows  one; 
or  more  limbs,  usually  the  lower,  painful  to  touch,  with  possibly  uniform 
swelling  above  the  knee  or  near  the  lower  end  of  the  tibia.  The  child's 
efforts  to  immobilize  the  affected  member  is  in  sharp  contrast  to  the 
restless  activity  normally  present.  The  temperature  may  be  only  slightly 
elevated,  normal  or  even  subnormal.  The  skin  may  show  petechia  or 
ecchymoses.  Examination  of  the  mouth  reveals  tumefaction  of  the 
gums,  or  there  may  be  only  a  faint  pink  line  along  the  gingival  border 
of  the  upper  jaw.  If  teeth  be  present  the  gingivitis  is  more  marked, 
purple  or  livid  tumefactions  almost  covering  the  crowns  of  the  teeth. 
Slight  pressure  may  cause  bleeding.  There  may  be  drooling  of  stained 
saliva  of  very  offensive  odor.  In  grave  cases,  the  gums  and  palate  may 
go  on  to  ulceration.  The  eyelids  may  be  swollen  and  dark  with  ecchy- 
mosis,  or  the  eyeball  protuberant  from  extravasation  of  blood  within  the 
orbit.  Diarrhoea  or  dysentery  may  occur  with  blood-streaked  mucoid 
stools,  or  there  may  be  history  of  recurrent  epistaxis. 

In  neglected  cases  the  picture  is  one  of  profound  cachectic  anaemia, 
with  fetid,  ulcerative  gums  and  swollen,  hard,  painful  limbs,  oedema  of 


198  DISORDERS    OF    NUTRITION 

the  extremities  and  apathetic  facies,  disturbed  only  by  motion  or  touch 
of  the  affected  members. 

Differential  Diagnosis. — The  diagnosis  is  to  be  made  from  rheuma- 
tism, for  which  it  is  most  frequently  mistaken,  especially  when  the  peri- 
osteal swellings  are  bilateral.  Careful  manipulation  will  show  the  free- 
dom of  the  joint  from  involvement  while  the  rise  in  temperature  is  not 
so  marked.  Although  the  purpuric  spots  may  simulate  rheumatic  pelio- 
sis  the  latter  does  not  show  the  extensive  gingivitis  of  scurvy.  It  should 
be  remembered  that  rheumatism  is  rare  at  the  age  when  purpura  is  com- 
mon. A  history  of  a  fall  or  blow  upon  the  afflicted  part  may  mislead  the 
mother  and  even  the  physician.  If  hemorrhage  is  sufficient  to  separate 
the  epiphysis  the  pain  and  crepitus  on  motion  may  simulate  the  effects 
of  violence.  The  above  mentioned  corroborative  symptoms  of  scorbutus 
should  quickly  affirm  the  true  nature  of  the  disorder. 

The  evidence  of  pain  on  handling,  especially  of  the  thorax  at  the 
costochondral  junction,  from  extravasation  of  blood  at  these  points,  may 
lead  to  the  diagnosis  of  rhachitis.  This  should  be  excluded  by  the  hemor- 
rhagic tendency  in  other  parts  of  the  body.  Purpura  hemorrhagica  sim- 
ulates scorbutus  in  so  many  points,  that  by  some  they  are  considered 
but  different  manifestations  of  a  blood  dyscrasia.  The  periosteal  lesions 
of  scorbutus,  however,  rarely  complicate  these  disorders.  Haemophilia 
need  not  be  mistaken  for  scorbutus,  if  due  attention  is  given  to  the  his- 
tory of  heredity,  and  previous  bleeding  and  careful  examination  be  made 
of  the  joint, — a  frequent  seat  of  hemorrhage  in  haemophilia.  Nor  is  the 
extensive  sponginess  of  the  gums  present  in  the  latter  disorder.  Opera- 
tions have  been  attempted  upon  scorbutic  lesions  of  the  periosteum  under 
the  mistaken  diagnosis  of  osteosarcoma  and  osteomyelitis.  A  physician 
familiar  with  the  symptoms  just  mentioned  will  rarely  make  this  mis- 
take. Haematuria,  hemorrhages  from  other  mucosae,  and  blood  examina- 
tion showing  absence  of  lymphocytosis  and  eosinophilia,  would  remove 
all  suspicion  as  to  the  presence  of  these  grave  lesions. 

Syphilitic  periostitis,  essentially  chronic  in  its  development,  is  pre- 
ceded, usually,  by  other  suggestive  lesions. 

Leukaemia,  with  its  splenic  and  glandular  enlargement,  aside  from  its 
distinctive  blood  picture,  should  occasion  but  little  trouble  in  differen- 
tiation. 

All  the  typical  lesions  of  a  well  developed  scorbutus  may  not  always 
be  present.  The  pain  on  motion  may  be  slight,  the  mouth  symptoms  may 
be  wanting,  or  at  best  a  faint,  pink  line  may  appear  at  the  base  of  the 
gums  or  a  deeper  pink  line  may  show  at  the  finger  nails.  Urinalysis, 
which  should  always  be  made,  may  reveal  albumin  and  only  a  rare  red 
corpuscle.  The  restlessness  may  be  attributed  to  an  ordinary  intestinal 
disturbance,  and  the  anaemia  without  local  hemorrhages,  to  malnutrition. 
In  such  and  all  doubtful  cases,  in  fact,  the  therapeutic  test  is  invaluable, 
as  many  suspected  cases  may  be  thus  relieved  by  the  timely  change  of 
diet  indicated  in  scorbutus. 

Treatment. — The  treatment  in  general  use,  because  almost  universally 


ADIPOSITAS  199 

successful,  is  the  substitution  of  raw  milk  for  the  pasteurized  or  steril- 
ized milk  or  carbohydrate  foods  in  use.  In  addition,  fruit  acids — as  the 
juice  of  grapes,  orange,  lemon,  or  pineapple — from  one  to  four  teaspoon- 
fills,  an  hour  distant  from  each  feeding,  will  rarely  fail  to  relieve  in 
a  few  days  all  hemorrhages  and  pain  incident  thereto.  Older  children 
may  eat  raw  fruits,— apples,  grapes,  oranges,  lemons,  etc.  Baked  pota- 
toes contain,  especially»near  the  skin,  a  high  percentage  of  potassium 
salts,  invaluable  in  scorbutic  conditions.  Boiled  spinach  is  useful  for 
the  same  reason. 

No  grave  disease  offers  a  more  satisfactory  field  for  successful  treat- 
ment. The  prompt  recovery,  from  simple  changes  in  the  food,  is  the  best 
evidence  of  its  dietetic  etiology.  Neglected  or  undiagnosed  cases  almost 
invariably  terminate  fatally  in  from  two  to  four  months.  The  extravasa- 
tions may  be  followed  by  suppuration  and  extensive  necrosis  of  bone  and 
other  tissues.  Death  may  be  due  to  some  intercurrent  disease,  such  as 
pneumonia,  cerebral  hemorrhage,  etc. 

ADIPOSITAS. 

Independent  of  Buhl's  disease,  excessive  fat  deposition  may  be  con- 
genital, or  adipositas  may  develop  during  the  nursing  period.  This  may 
be  accompanied  by  weak  musculature  and  lax  ligaments  without  other 
signs  of  rhachitis.  Usually  in  infants  the  fat  may  be  reduced  by  daily 
massage,  reduction  of  the  carbohydrates  and  hydrocarbon  in  the  food, 
the  use  of  vegetable  acids  in  fruit  juices — orange,  lemon,  grape  and 
apple — and  the  administration  of  alkalies,  such  as  sodium  or  potassium 
bicarbonate. 

In  later  childhood  adipositas  may  prove  serious  and  intractable,  espe- 
cially when  accompanied  by  anaemia  and  fatty  heart.  The  muscles  are 
weak  and  general  debility  may  supervene  with  dyspnoea  and  tachycardia. 

In  addition  to  the  above  considerations  in  diet,  water  ingestion  should 
be  limited.  (These  children  are  great  drinkers  and  overload  the  weak 
heart.)  Exercise  up  to  the  safety  limit,  with  thorough  daily  massage,  is 
important.  In  extreme  cases  thyroid  extract  or  iodothyrin  may  be  cau- 
tiously administered. 

The  type  is  occasionally  familial,  and  these  children  fall  easy  vic- 
tims to  intercurrent  disease. 

OSTEOMALACIA. 

A  number  of  bony  defects  resemble  rhachitis  in  the  paucity  of  lime 
salts.  Among  these  are  osteomalacia  and  osteopsathyrosis.  (For  Achon- 
droplasia, Cranial  Dysostosis,  and  Osteogenesis  Imperfecta,  see  page  163.) 

Osteomalacia,  although  a  disease  of  adult  life,  is  occasionally  met 
with  in  children,  and  a  few  congenital  cases  have  been  reported.  It  is 
claimed,  however,  that  the  latter  are  cases  of  achondroplasia  or  so-called 
fetal  rickets. 

In  osteomalacia  the  lime  salts  are  deficient,  as  though  the  bones  had 
been  soaked  in  dilute  hydrochloric  acid,  so  that  they  yield  readily,  bend- 


200  DISORDERS    OF    NUTRITION 

ing  or  fracturing  under  slight  strain.  Unlike  rickets  there  is  no  in- 
creased deposition  of  bone  under  the  periosteum  to  compensate  for  the 
rapid  absorption  from  the  medullary  surface.  Neither  do  they  show 
rhachitic  enlargements  of  the  epiphyses.  The  fragilitas  ossium  leads  to 
innumerable  fractures  with  resulting  deformities,  all  of  which  are  pain- 
fully tender  under  pressure  and  slow  of  repair.  To  all  the  deformities 
of  rhachitis,  save  those  of  epiphyseal  enlargements  and  rib  beading,  are 
added  reparative  callosities  from  united,  and  pseudarthroses  from 
ununited  fractures. 

The  congenital  types  are  either  still-born  or  succumb  early  to  inani- 
tion, while  those  who  survive  early  infancy  readily  become  marantic  or 
fall  an  easy  prey  to  intercurrent  disease. 

Osteomalacia,  occurring  in  later  childhood,  retards  pubescence,  a  con- 
dition of  infantilism  persisting.  Angemia  is  present  with  amenorrhoea 
in  girls.  The  tendency  to  bone  fractures  is  associated  with  muscular 
atony  and  often  extreme  debility.  Few  of  these  children  reach  adult 
life. 

The  only  known  treatment  is  indicated  by  the  pathology:  Iron  and 
arsenic  for  the  ana?mia ;  phosphorus,  cod-liver  oil,  sea  air  and  bathing, 
with  glycerophosphates  of  lime  and  the  compound  hypophosphites,  for 
the  bones. 

OSTEOPSATHYROSIS. 

Osteopsathyrosis  is  a  term  applied  to  a  form  of  fragilitas  ossium, 
with  tendency  to  fracture,  which  is  occasionally  seen  in  infancy  and 
childhood.  It  differs  from  rhachitis  in  the  absence  of  typical  enlarge- 
ments, and  from  osteomalacia  in  the  greater  rigidity,  less  frequent  bend- 
ing from  bone-softening,  and  in  the  absence  of  pain,  especially  in  the 
upper  limbs,  at  the  seat  of  fracture. 

The  bones  are  small  and  brittle  and  show  paucity  of  lime ;  the 
muscles  are  atonic  and  the  ligaments  relaxed,  allowing  subluxation  at 
the  joints.     The  prognosis  is  discouraging. 

Treatment  is  the  same  as  for  osteomalacia,  with  careful  oil  massage 
and  avoidance  of  active  exertion  that  will  jeopardize  the  fragile  bones. 


CHAPTER    IV 

DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

THE    LIPS,  TONGUE,  AND    MOUTH 

MACROCHEILIA — HYPERTROPHY    OF    THE    LIPS 

The  lips — more  frequently  the  upper — may  be  greatly  thickened  and 
elongated,  to  such  an  extent  as  to  constitute  a  deformity.  Hypertrophy 
of  the  lip  is  occasionally  seen  as  a  result  of  local  lesions  of  the  mucosa 
from  long  continued  irritation,  especially  in  children  of  the  lymphatic 
diathesis.     In  them  it  constitutes  a  form  of  lymphangitis. 

Congenital  macrocheilia,  when  unsightly,  may  be  corrected  by  a 
surgical  operation  which  consists  in  the  removal  of  a  wedge-shaped  por- 
tion of  the  free  border  of  the  lip. 

PERLECHE LICKING  DISEASE  OF  THE  LIPS 

Perleche  is  an  infectious  disorder  of  the  lips  seen  most  frequently  in 
school  children  who  are  exposed  by  common  use  of  drinking  cups,  pen- 
cils, whistles,  etc.  Strepto-  and  staphylococci  have  been  found  in  the 
lesion. 

The  lips,  beginning  at  the  angles  of  the  mouth,  become  hot  and  swol- 
len, and  fissures  occur  in  the  mucous  membrane,  which  becomes  macer- 
ated, thickened,  and  opaque,  and  comes  off  in  patches  and  strips. 

There  is  itching  and  smarting,  which  leads  to  constant  licking  (hence 
the  name),  which  increases  the  irritation.  The  disease  lasts  two  or  three 
weeks  and  must  not  be  confounded  with  herpes  of  the  mouth  or  facial 
eczema,  either  of  which  may  complicate  it.  The  treatment  consists  in 
cleanliness  and  the  use  of  astringents,  such  as  alum,  sulphate  of  cop- 
per, or  nitrate  of  silver,  in  weak  solution.  If  very  moist  and  sodden 
the  mucosa  of  the  lip  may  be  dusted  with  bismuth  subnitrate  and  zinc 
oxide  in  equal  parts.  Prophylaxis  requires  separate  drinking  cups,  eat- 
ing utensils,  towels,  etc. 

MACROGLOSSIA — HYPERTROPHY  OF   THE   TONGUE 

Aside  from  the  congenital  macroglossia  which  is  usually  associated 
with  other  defects,  as  in  cretins  and  imbeciles,  the  tongue  may  become 
greatly  enlarged  by  an  increase  of  all  or  any  of  its  constituent  tissues. 
There  may  be  muscular  hypertrophy  or  overgrowth  of  fibrous  tissue  at 
the  expense  of  muscular  structure.  Cystic  degeneration  of  interstitial 
tissue  may  occur,  or  overdistention  of  lymph-spaces,  with  resultant  de- 

201 


202  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

velopment  of  cavernous  lymphangioma.  The  lymphoid  bodies  may 
hypertrophy,  causing  lymphaclenoma,  or  lipomatous  masses  may  enter 
into  the  lingual  enlargement.  In  any  case,  the  mouth  may  be  too  small 
to  hold  the  tongue  which,  pressing  against  the  teeth,  gives  them  a  for- 
ward inclination  and  results  in  erosions  of  the  mucous  membrane  by 
friction.  This  irritation  in  turn  increases  the  swelling  and  hypertrophy, 
while  desiccation  of  drooling  saliva  and  decomposing  secretion  upon  the 
projecting  portion  of  the  tongue,  with  its  foul  odor,  produces  sometimes 
a  disgusting  and  painful  condition. 

The  relief  of  macroglossia  is  purely  surgical, — by  abbreviation  or 
by  excision  of  a  portion  of  the  organ.  In  some  forms,  the  hypertrophy 
may  be  arrested  by  ligation  of  its  arteries. 

ACUTE  GLOSSITIS. 

Acute  glossitis,  or  inflammation  of  the  tongue,  although  rare  in 
childhood,  is  occasionally  seen  from  traumatisms  due  to  burns,  pricks, 
stings,  bites,  erosions  from  carious  teeth,  or  any  lesion  which  allows 
entrance  to  infectious  organisms.  It  may  occur  as  a  complication  of 
tonsillitis  or  any  acute  angina.  The  inflammation  extends  to  the  deeper 
structures  through  abrasions  of  the  mucous  membrane. 

The  symptoms  are  fever,  increased  salivation,  pain  and  swelling  of 
the  tongue,  which  may  entirely  fill  the  cavity  of  the  mouth,  protruding 
beyond  the  teeth,  so  that  introduction  of  food  and  even  fluids  is  attended 
with  great  difficulty.  The  swelling  may  extend  backward  so  as  to  threaten 
respiration  from  pressure  on  the  glottis.  Exceptionally,  an  abscess  may 
form  in  the  deep  structure  of  the  tongue.  In  this  case  the  distention 
may  be  so  great  as  partially  to  bury  the  upper  incisors  in  the  dorsum 
of  the  organ. 

In  mild  cases  the  treatment  should  consist  in  free  purgation,  anti- 
septic mouth  washes,  pieces  of  ice  allowed  to  dissolve  in  the  mouth,  and 
liquid  diet.  In  severe  cases  free  incisions  should  be  made  along  the  dor- 
sum, parallel  with  the  median  line.  Where  the  distention  is  great,  a 
thin  curved  depressor  may  be  insinuated  between  the  dorsum  and  upper 
incisors,  along  which  a  gum  lancet  may  be  introduced  on  the  flat,  and 
then  turned  with  its  cutting  edge  downward  and  quickly  withdrawn, 
making  a  free  incision  an  inch  or  more  in  length. 

The  exit  of  blood  and  pus  will  relieve  the  swelling,  dyspnoea,  and 
other  urgent  symptoms,  after  which  the  mouth  and  wound  should  be  fre- 
quently cleansed  with  boric  acid  solution. 

LINGUA   GEOGRAPHICA — DESQUAMATIVE    GLOSSITIS;     PITYRIASIS  LINGUiE. 

These  are  terms  applied  to  a  tongue  which  shows  pale  pink,  circum- 
scribed areas  denuded  of  epithelium,  bounded  by  whitish  circular  zones 
of  elongated  filiform  papilke.  There  may  be  from  one  to  a  dozen  of 
these  patches  over  the  dorsum  of  the  tongue,  but  they  are  most  fre- 
quently seen  near  its  edge.    They  vary  in  shape  from  time  to  time  as  the 


GLOSSITIS  2(j:J 

alternation  of  papillary  hypertrophy  and  epithelial  desquamation  pro- 
ceeds. The  intermingling  of  the  whitish  boundaries  of  these  pale,  glazed 
areas  gives  to  the  circular  borders  a  serpentine  appearance,  so  that  a 
great  variety  of  patterns  may  be  seen  at  different  times.  This  has  given 
rise  to  the  term  "geographical  tongue."  The  process  of  desquamation 
is  probably  due  to  the  action  of  micro-organisms,  the  nature  of  which 
is  as  yet  unknown. 

It  is  seen  most  frequently  in  childhood  and  bears  no  relation  to  any 
other  disease.  The  child  suffers  no  discomfort  and  exhibits  no  dis- 
turbance of  function.  It  appears  most  frequently  in  bottle-fed  infants 
and  a  relation  to  rhachitis  is  suggested,  although  the  claim  for  syphilitic 
causation  has  been  adequately  disproven. 

The  condition  has  little  clinical  significance  save  as  a  curiosity,  and 
its  recognition  is  only  valuable  to  prevent  confusion  with  other  con- 
ditions of  diagnostic  importance. 

The  duration  of  these  epithelial  changes  is  indefinite  and  may  con- 
tinue, with  variations,  for  many  years.    No  treatment  is  indicated. 

ULCER  OF  THE  TONGUE. 

An  ulcer  on  the  under  side  of  the  tongue,  just  in  front  of  the  fraa- 
num,  is  occasionally  seen  in  infants  after  the  eruption  of  the  lower 
median  incisors.  It  is  commonly  associated  with  pertussis  or  with  any 
cough  that  is  violent  or  frequently  repeated.  (This  ulcer  is  caused  by 
rasping  the  protruding  tongue  against  the  sharp  edges  of  the  incisors 
during  fits  of  coughing.)  It  is  usually  shallow,  from  two  to  six  milli- 
metres in  diameter,  is  indolent  in  character,  and  shows  little  tendency 
to  bleeding  and  suppuration.  No  treatment  is  necessary,  other  than 
astringent  antiseptic  applications,  as  prompt  healing  follows  the  cessation 
of  the  cough. 

Riga's  disease. 

Eiga's  disease  is  a  name  given  to  a  sublingual  growth  one-quarter  inch 
(0.6  Cm.)  in  diameter,  which  begins  as  an  ulceration  in  the  site  above 
mentioned.  It  is  described  as  occurring  endemieally  in  southern  Italy 
independent  of  cough  or  other  known  cause.  Only  a  few  cases  have 
been  reported  outside  of  Italy.  A  characteristic  bacillus  is  claimed  to 
have  been  found  in  the  milk  of  the  mother  and  organs  of  her  infant 
dying  from  this  disease.  Reports  agree  in  regard  to  the  indurated 
character  of  the  lesion,  which  assumes  the  proportions  of  a  sessile,  disk- 
like  tumor,  made  up,  chiefly,  of  hypertrophied  epithelium  and  con- 
nective tissue  infiltrated  with  a  large  mass  of  round  cells  embedded  in 
fibrin. 

Among  the  anomalous  characteristics  ascribed  to  these  growths  are 
the  non-involvement  of  adjacent  lymph  nodes,  early  recurrence  of  the 
growth  after  its  removal  (which  is  readily  effected  without  hemorrhage), 
its   disproportionate   associated   disturbances,   such   as   gastro-intestinal 


201  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

disorder,  enlargement  of  liver  and  spleen,  with  marasmus,  and  frequent 
fatal  terminations.  Recently  reported  cases  give  a  more  benign  char- 
acter to  this  growth  and  good  results  after  excision. 

RANULA. 

A  tumor  is  occasionally  seen  in  the  floor  of  the  infant's  mouth, 
varying  in  size  from  a  pea  to  a  chestnut  or  even  larger.  If  situated  at 
one  side  of  the  frenum  or  involving  that  structure,  and  if  translucent, 
pearl-colored,  thin-walled,  and  fluctuating,  it  is  probably  a  ranula.  This 
is  a  cystic  tumor  due  to  the  blocking  of  the  mouth  of  a  mucous  follicle, 
or  to  a  congenital  occlusion  of  the  glands  of  Nuhn.  It  is  filled  with  a 
glairy,  transparent  fluid,  and  when  evacuated  the  cyst  walls  are  col- 
lapsible. The  tumor  is  painless  and,  if  small,  affords  no  inconvenience. 
It  may  be  so  large  as  to  interfere  with  nursing  and,  in  older  children, 
it  may  render  speech  and  deglutition  difficult. 

Cysts  in  this  locality  may  be  caused  by  the  occlusion  of  Wharton's, 
duct,  or  the  ducts  of  Bartolini  and  Rivinus,  by  salivary  calculi.  These 
do  not,  however,  constitute  true  ranuhe.  Dermoid  cysts  from  con- 
genital persistence  of  a  branchial  cleft  may  encroach  upon  the  floor  of 
the  mouth,  but  may  be  differentiated  by  their  deeper  situation,  lack  of 
translucency,  and  denser  feel,  their  contents  being  sebaceous  matter  and 
epidermal  detritus. 

Ranula?  may  be  readily  emptied  by  simple  incision,  but  the  prompt 
healing  of  the  sac  is  followed  by  refilling.  Its  extermination  requires 
excision  of  a  good  portion  of  its  anterior  wall,  with  the  application 
of  the  solid  nitrate  of  silver  to  promote  shrinkage  and  obliteration  of 
the  sac. 

Occlusion  by  salivary  calculi  and  distention  of  the  ducts  from  re- 
tained secretion  may  be  relieved  by  a  probe  introduced  into  the  orifices, 
and  gentle  massage  to  dislodge  the  concretions.  Failing  in  this  a  more- 
extensive  surgical  operation  will  be  necessary. 

TONGUE-TIE — ELONGATIO   FRENTJLI. 

Tongue-tie  is  a  condition  in  which  protrusion  and  free  mobility  are 
restricted  by  the  extent  of  the  frenular  attachment  which,  in  some  cases, 
reaches  to  the  extreme  tip  of  the  organ.  This  occurrence  is  rare,  how- 
ever, and  the  condition  has  been  unduly  magnified  as  a  possible  obstacle 
to  nursing.  Occasionally,  in  older  children,  defects  in  speech  are  at- 
tributed to  this  cause.  Greater  freedom  may  be  allowed  the  tip  of  the 
tongue  by  snipping  with  blunt  scissors  the  anterior  border  of  the  frenum 
near  its  attachment  to  the  floor  of  the  mouth,  pointing  downward  to  avoid 
wounding  the  ranine  arteries. 

This  operation  is  rarely  needed  and  should  never  be  undertaken 
without  inquiring  concerning  a  history  of  hemophilia.  Undue  ex- 
tension of  the  incision  from  laceration  may  result  in  retrolapsus  of  the 
tongue. 


DENTITION  205 


DIFFICULT    DENTITION. 

The  relation  of  dentition  to  the  disturbances  of  infancy  has  been  a 
much-mooted  question,  it  having  been  held  by  many  that  a  purely  physio- 
logical process  could  not  be  held  responsible  for  pathologic  conditions  in 
remote  and  unassociated  organs  and  tissues.  The  consensus  of  opinion, 
however,  derived  from  clinical  observation,  is  found  to-day  occupying  a 
middle  ground  between  that  of  a  previous  generation  which  blindly 
attributed  most  of  the  ailments  of  infancy  to  dentition  and  that  class 
of  moderns  who  stoutly  proclaim  that  teething  produces  nothing  but 
teeth. 

That  either  radical  view  is  productive  of  much  harm  is  apparent  in 
the  number  of  lost  opportunities  for  the  early  relief  of  grave  conditions, 
due  to  the  mistaken  diagnosis  of  "teething,"  on  the  one  hand,  and  in 
the  neglect  to  recognize  the  existence  of  pain  and  serious  reflex  dis- 
turbances, caused  by  abnormal  dentition,  on  the  other. 

From  the  multitude  of  clinical  facts  and  an  analytical  study  of 
the  relationship  of  the  innervation  of  certain  parts  to  the  circulation  in 
other  parts,  it  is  not  difficult  to  see  why  a  process  so  commonly  accom- 
panied by  elevation  of  temperature,  local  congestion,  pain,  anorexia, 
tenderness,  irritability,  restlessness,  and  a  loss  of  weight,  should  at  least 
act  as  a  predisposing  cause  to  many  pathological  processes,  in  which 
congestion  is  a  preliminary  stage.  Otalgia,  if  not  suppurative  otitis ; 
cerebral  hyperemia,  if  not  meningitis ;  disturbed  digestion,  if  not  en- 
teritis, and  many  other  manifestations  of  profound  derangement  of  the 
nervous  equilibrium  may  be  attributable,  directly  or  indirectly,  to  diffi- 
cult dentition. 

The  normal  process  of  development  and  eruption  of  the  teeth  has 
been  described  elsewhere  (Part  I),  so  that  a  few  abnormalities  only 
need  be  mentioned.  That  the  general  nutrition  of  the  infant  has  an 
important  influence  over  the  character  of  the  teeth  is  evident,  as  in  rha- 
chitic  malnutrition  the  teeth  may  come  through  out  of  the  usual  order, 
most  frequently  the  incisors  appearing  singly  instead  of  in  pairs,  the 
upper  preceding  the  lower.  Early  dentition  is  often  attributable  to 
rhachitis,  in  which  case  the  teeth  are  fragile  and  decay  quickly.  Usually, 
however,  rhachitis  causes  late  dentition,  and  a  year  or  eighteen  months 
may  have  elapsed  before  the  first  crown  shows  through  the  gums.  The 
narrowing  of  the  alveolar  ridges,  in  the  plastic  state,  from  pressure 
of  lips,  teeth,  and  tongue,  is  claimed  to  be  partly  responsible  for  delayed 
and  irregular  eruption,  while  paucity  of  earthy  salts,  a  known  condition 
of  rhachitis,  is  undoubtedly  one  cause  of  retarded  and  irregular  growth  of 
the  teeth.  Other  forms  of  malnutrition  and  disease  leave  their  impress 
upon  tooth  formation,  in  defective  dentine  and  enamel,  as  seen  in  the 
horizontal  ridges  and  grooves  caused  by  acute  infections  and  syphilis. 
The  well  known  deformities  of  the  last  named  is  referred  to  under  that 
subject  (Part  I).  The  unstable  functions  of  the  developing  period 
coincident  with  dentition,  the  most  important  of  which  is   digestion, 


206  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

should  warn  us  to  safeguard  it  by  special  attention  to  diet.  When 
the  eruption  of  groups  of  teeth  is  imminent  the  food  should  be  reduced 
and  plenty  of  water  given  to  relieve  the  thirst  so  commonly  mistaken 
for  hunger.  The  hot  and  swollen  gums  should  be  protected  against  in- 
fection by  antiseptic  lotions.  The  restlessness  and  nervous  condition 
of  the  infant  may  well  merit  mild  sedatives,  as  bromide  of  sodium  in 
full  doses,  frequently  repeated,  and  avoidance  of  all  that  tends  to  dis- 
turb or  fatigue.  The  suffering  of  the  screaming,  irritable  infant,  as 
the  tooth-crown  approaches  the  surface,  is  usually  due  either  to  the  over- 
lying tissue,  in  which  case  the  gum  is  swollen,  congested,  hot,  and  tender, 
or  to  reflex  or  congestive  pains  in  other  localities,  usually  the  middle 
ear.  In  the  former  case  the  symptoms  may  be  relieved  by  the  gum 
lancet  which  should  be  used  with  aseptic  care,  cutting  down  full  upon 
the  crown,  with  a  linear  incision,  if  it  be  an  incisor,  or  with  a  crucial 
incision,  if  it  be  a  molar ;  in  the  latter  instance  so  directed  as  to  relieve 
the  pressure  over  each  of  the  four  advancing  cusps.  If  the  gum  be  not 
swollen,  hot,  and  tender,  the  lance  is  useless  and  relief  of  pain  must  be 
sought  in  hot  or  anodyne  applications  to  the  painful  area.  In  either  case 
bromide  of  sodium,  two  to  five  grains  (0.13-0.32  Gm.)  in  syrup  of 
lactucarium,  one-half  to  one  teaspoonful,  may  be  given  at  intervals  of 
two  hours,  until  rest  is  secured. 

The  difficulties  of  second  dentition  may  be  obviated  in  a  great  meas- 
ure by  intelligent  care  of  the  deciduous  teeth,  in  the  prevention  of  early 
decay  and  loss  before  the  development  of  the  alveolar  structures  so 
essential  to  a  symmetrical  arrangement  of  their  successors.  The  mouth 
disorders,  alveolar  abscesses,  and  toothache,  so  common  to  the  period  of 
second  dentition,  may  be  minimized  by  daily  care  with  brush  and  soap, 
and  frequent  inspection  for  defects. 

CATARRHAL   STOMATITIS — STOMATITIS    CATARRHALIS. 

The  commonest  affection  of  the  mouth  in  infancy  is  simple  catarrhal 
inflammation.  In  fact,  this  form  precedes  and  accompanies  all  other 
forms  of  stomatitis.  It  may  be  due  to  traumatism,  from  hot  or  corrosive 
substances,  or  from  abrasions  of  the  delicate  mucosa  by  misdirected 
efforts  in  cleansing  the  oral  cavity.  The  artificial  nipple  of  the  nursing 
bottle  may,  if  not  properly  adjusted  to  the  size  of  the  infant's  mouth, 
cause  irritation  or  erosion.  Disease  and  malnutrition  play  an  important 
part  in  the  lowered  resistance  of  the  mucosa  to  the  infectious  organisms 
ever  present  in  the  infant's  mouth.  The  perverted  action  of  the  se- 
cretory glands  may  lead  to  the  excretion  of  irritating  substances  from 
infections  and  toxin  absorption  in  other  parts  of  the  body.  Hence  the 
frequent  occurrence  of  stomatitis  in  gastro-enteric  infection.  All  gen- 
eral infectious  diseases  cause  hyperemia  or  inflammation  of  the  mucous 
membrane  of  the  mouth.  It  is  here  that  the  first  lesions  appear  in 
nearly  all  the  acute  exanthemata. 

There  may  be  in  acute  catarrhal  stomatitis  only  a  general  or  local 
hyperemia  and  hypersensitiveness,  or  the  membranes  may  be  greatly  in- 


STOMATITIS  207 

flamed,  with  pain,  tenderness,  and  increased  secretion  of  tenacious,  glairy 
mucus.  There  may  be  fever,  restlessness,  thirst,  and  disinclination  to  take 
food,  on  account  of  the  pain  induced.  The  nursling  refuses  the  breast. 
The  tongue  is  coated  and  the  bowels  are  commonly  constipated  although 
diarrhcea  may  precede  and  accompany  the  attack.  The  drooling  of  acrid 
saliva  may  irritate  the  lower  lip  with  resultant  swelling  and  excoriations. 
Other  lesions  of  the  mouth  due  to  infectious  organisms,  following  in  the 
wake  of  simple  catarrhal  inflammation  and  lowered  nutrition  from  ina- 
bility to  take  food,  is  a  common  result  of  long-continued  painful  mouth 
disease.  Uncomplicated  catarrhal  stomatitis,  however,  is  usually  of 
short  duration  with  a  tendency  to  recovery  upon  the  removal  of  the 
exciting  cause.     The  prognosis  is  therefore  good. 

The  treatment  consists  in  the  avoidance  of  acrid  substances  or  the 
irritating  products  of  decomposing  food,  and  the  application  of  soothing 
antiseptic  washes,  such  as  sodium-bicarbonate,  boric  acid,  potassium  per- 
manganate, or  sterilized  water.  Obstinate  cases  may  require  painting  the 
inflamed  membrane  with  a  weak  solution  of  nitrate  of  silver  (0.5-1  per 
cent.).  Indigestion  must  be  corrected  and  bowel  disturbance  relieved  by 
efficient  laxatives  or  high  colonic  flushings. 

STOMATITIS    APHTHOSA — STOMATITIS    HERPETICA ;      VESICULAR    STOMATITIS; 
FOLLICULAR  STOMATITIS;     CANKER  SORE  MOUTH. 

The  mucous  membrane  of  the  mouth  is  frequently  the  seat  of  an  her- 
petic eruption — stomatitis  herpetica.  The  age  of  greatest  susceptibility 
corresponds  somewhat  closely  to  the  period  of  first  dentition,  to  which 
many  ascribe  etiologic  significance.  Its  occurrence  in  babies  at  the  breast 
is  not  as  frequent  as  in  those  fed  from  the  bottle.  Simple  aphthous  ulcers 
are  occasionally  seen  in  adults.  Stomatitis  aphthosa  is  usually  attended 
in  children  by  febrile  disturbance  and  malaise.  The  temperature  may 
reach  103°  F.  (39.5°  C).  The  tongue  is  coated  and  there  is  often  diges- 
tive disturbance,  with  green,  foul-smelling  stools.  The  lesions,  if  seen 
early,  appear  as  round  or  oval,  slightly  raised  pearly  spots  from  one  to 
five  millimetres  in  diameter.  Of  these  there  may  be  one  or  a  dozen,  occur- 
ring singly  or  in  groups.  The  most  common  site  is  on  the  margin  of  the 
tongue  or  inner  surface  of  the  lower  lip  at  its  junction  with  the  gum, 
although  the  first  appearance  may  be  as  a  solitary  vesicular  lesion  on  the 
tonsil.  Within  twenty- four  hours,  in  exceptional  cases,  the  mucous  mem- 
brane, especially  about  the  fauces,  may  be  studded  with  the  eruption, 
which  tends  to  coalesce,  forming  a  continuous  patch  or  plaque.  The 
patches  of  coalescence  at  times  resemble  a  diptheritic  exudate,  for  which 
it  is  occasionally  mistaken.  The  epithelial  covering  disappears,  leaving 
the  discrete  vesicle  as  a  shallow  ulcer,  with  a  white  or  yellowish  base, 
surrounded  by  a  zone  of  hyperaemic  tissue.  The  lesions  are  extremely 
sensitive.  The  salivary  secretion  is  excessive,  and  in  the  drooling  infant 
may  cause  irritation  and  excoriation  of  the  lip  and  chin.  A  peculiarity 
of  these  shallow  lesions  is  the  absence  of  the  fetid  breath  so  characteristic 
of  ulcerative  stomatitis.     The  painful  lesions  interfere  with  feeding  or 


208  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

any  motion  of  the  tongue.  The  child  is  irritable  and  restless.  The  dura- 
tion, if  uncomplicated,  is  from  three  to  seven  days,  although  a  succession 
of  crops  may  continue  the  affection  for  two  or  three  weeks.  The  exuda- 
tive floor  of  the  shallow  ulcer  is  gradually  raised  above  the  level  of  the 
surrounding  epithelium,  and  cast  off  with  spontaneous  healing  and  with- 
out cicatrization. 

Pathologically,  this  form  of  stomatitis  closely  resembles  herpes  of  the 
skin,  from  which  it  differs  only  in  the  peculiarities  of  its  location.  A 
point  of  resemblance  is  seen  in  the  diseases  which  they  commonly  ac- 
company, such  as  pneumonia,  typhoid,  malaria,  and  indigestion.  No 
specific  organism  has  as  yet  been  found  in  aphtha?,  and  it  is  generally 
regarded  as  a  result  of  toxins  which  affect  the  terminal  filaments  of  the 
superficial  nerves. 

The  discovery  of  its  coincidence  with  epidemics  of  mouth-and-foot 
disease  in  cattle  has  excited  great  interest  in  the  question  of  its  trans- 
missibility.  Under  certain  conditions  it  appears  to  be  contagious,  al- 
though the  mass  of  clinical  evidence  tends  to  the  contrary,  in  the 
ordinary  form  of  the  disease. 

Diagnosis. — It  is  to  be  diagnosed  from  ulcerative  and  diphtheritic 
stomatitis  and  from  the  lesions  of  variola  and  varicella,  as  they  oc- 
casionally appear  in  the  mouth.  The  absence  of  fetor  and  the  location 
of  the  ulcers  may  exclude  the  first  named,  and  the  early  disappearance 
of  the  rare  coalesced  patches  proves  its  non-diphtheretic  character.  The 
nature  of  varicellar  and  variolous  lesions  of  the  oral  mucosa  is  revealed 
by  the  concurrent  or  subsequent  eruption  on  the  skin. 

Prognosis. — The  prognosis  is  favorable  in  the  great  majority  of  cases. 
Occasionally,  some  of  the  lesions  become  infected  and  develop  into  an 
ulcerative  stomatitis. 

Treatment. — The  treatment  is  essentially  the  same  as  for  the  catarrhal 
variety,  in  addition  to  which  the  ulcers  may  be  gently  touched  with 
tincture  of  chloride  of  iron,  or  the  pencil  of  mitigated  lunar  caustic. 
If  the  infant  refuses  to  nurse,  it  may  be  fed  with  the  stomach-tube  in- 
troduced through  the  nose.  Older  children  may  be  given  ice  cream,  if 
not  contraindieated,  as  warm  fluids  cause  pain. 

BEDXAR'S   APHTH/E — APHTHJE   OF    THE   PALATE. 

Among  the  ulcerative  lesions  of  the  mouth  should  be  mentioned  Bed- 
nar's  aphtha?,  which,  according  to  the  American  classification,  may  be 
considered  a  misnomer.  Bednar's  aphtha?,  or  plaques  pterygoidiennes, 
appear  usually  as  a  double  lesion  of  the  mucous  membrane  on  opposite 
sides  of  the  mouth  at  about  the  line  of  junction  between  the  hard  and 
soft  palate.  Occasionally  these  erosions  occur  in  the  median  line  from 
denudation  of  the  epithelial  pearls  there  situated.  They  are  due  to 
superficial  erosions  from  traumatism  of  the  mucous  membrane  covering 
the  hamular  processes  of  the  pterygoids.  The  finger,  the  artificial  nip- 
ple, or  even  the  base  of  the  baby's  tongue  in  nursing-,  may  cause  erosions 
of  the  delicate  epithelium  over  these  unyielding  portions  of  the  palate. 


STOMATITIS  209 

Subsequent  infection,  ulceration,  necrosis,  and  even  sloughing  may  ensue, 
with  production  of  the  symmetrical  characteristic  Lesions  described  first 
by  Bednar.  Rarely  the  ulcerative  process  may  extend  until  the  entire 
mucosa  of  the  soft  palate  is  involved.  It  occurs  during  the  first  month 
of  life  and  with  greater  frequency  in  babies  fed  from  the  bottle,  espe- 
cially in  those  of  low  vitality,  with  unsanitary  surroundings. 

The  treatment  requires  removal  of  the  cause.  The  artificial  nipple 
should  be  abbreviated  and  rough  cleansing  of  the  mouth  must  be  stopped. 
If  the  ulcers  prove  obstinate  the  infant  may  be  fed  with  a  spoon  or  by  a 
tube  introduced  through  the  nose. 

Topical  applications  are  necessary  as  for  other  ulcerative  conditions 
of  the  mouth.  The  healing  is  usually  prompt  after  removal  of  the 
cause  of  irritation. 


STOMATITIS     MYCOSA MYCETOGENIC     STOMATITIS;      PARASITIC     STOMATITIS; 

THRUSH;     MUGUET ;     SPRUE;     SOOR. 

Stomatitis  mycosa  is  a  disease  produced  by  a  vegetable  parasite  in  the 
form  of  a  fungus  growth,  probably  a  mould,  though  its  precise  classifica- 
tion is  still  a  matter  of  dispute. 

The  spores  of  this  fungus  are  everywhere  present  in  the  air,  and  may 
be  found  in  the  mouths  of  healthy  infants.  In  fact,  there  is  no  cavity  or 
tissue  of  the  body  in  which  they  may  not  be  found.  They  cause  stoma- 
titis when  the  oral  mucosa  furnishes  a  favorable  soil  for  the  growth  of 
the  mycelium  and  reproduction  of  spores, — i.e.,  when  fissures  or  erosions 
exist,  or  the  membrane  is  softened  by  a  catarrhal  stomatitis.  Finding 
lodgement  they  multiply  between  the  epithelial  cells,  which  are  crowded 
aside  and  destroyed  until  the  fungus  appears  upon  the  surface  of  the 
mucosa  in  the  form  of  small  white  flakes,  which  closely  resemble  milk 
curds,  for  which  they  are  frequently  mistaken.  Attempts  to  remove  these 
flakes,  however,  will  show  the  mistake,  as  they  adhere  quite  firmly  and, 
when  dislodged  by  forcible  wiping,  leave  abraded  surfaces  which  may 
bleed  slightly.  The  adjacent  mucosa  is  less  moist  than  usual  and  the 
oral  secretions  are  slightly  acid.  The  white  flakes  are  usually  first  seen 
upon  the  tongue  and  buccal  membrane  where  they  multiply  rapidly  and 
spread  over  the  adjacent  surfaces  covering  the  palate,  fauces  and  uvula 
with  a  thick,  whitish  mass  which  occasionally  resembles  a  pseudomem- 
brane.  The  growth,  if  unchecked,  may  spread  over  the  lips  and  invade 
the  oesophagus,  and  has  been  found  in  the  stomach,  though  such  occur- 
rences are  rare  in  this  country.  The  disease,  in  itself,  is  not  painful  but 
the  attending  catarrhal  stomatitis  may  occasion  much  discomfort.  Rarely 
other  infections  supervene,  and  ulcers  form  with  painful  lesions  and 
bad  breath. 

Thrush  is  essentially  a  disorder  of  the  early  suckling  period,  although 
it  may  occur  at  any  period  of  infancy  under  favorable  conditions, — 
namely,  feeble  mobility,  lowered  resistance,  and  implantation  of  the 
specific  fungus  upon  a  surface  denuded  of  epithelium.     It  is  seen  in 

14 


210  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

the  mouths  of  patients  in  extreme  debility,  and  is  an  occasional  pre- 
cursor of  death  in  exhausting  disease. 

Thrush  is  due  to  lack  of  aseptic  care  of  the  nipple  or  of  any  substance 
that  is  introduced  into  the  mouth.  The  disease  is  not  self -limiting,  and 
results  in  athrepsia  from  extension,  or  from  associated  infections  which 
interfere  with  feeding  and  digestion. 

The  prognosis  is  good  under  proper  treatment,  which  consists  in 
thorough  cleansing  of  the  mouth  with  a  solution  containing  borax  twenty 
grains  (1.3  Gm.),  glycerin  two  drachms  (7.5  C.c).,  and  rose-water  two 
ounces  (60  C.c.)  ;  or,  sodium  bicarbonate  ten  grains  (0.65  Gm. )  to  the 
ounce  (30  C.c.)  of  water,  in  milder  cases.  The  mouth-wash  should  be 
applied  with  a  gauze  swab  before  and  after  feeding,  with  care  to  avoid 
further  abrasion  of  the  delicate  mucosa. 

Prophylaxis  is  all-important,  as  mycetogenic  stomatitis  in  all  its 
forms  is  readily  transmissible ;  hence  the  prevalence  of  thrush  in  insti- 
tutions for  babies  where  strict  aseptic  precautions  are  neglected. 

STOMATITIS    ULCEROSA — ULCERATIVE    STOMATITIS;     PUTRID    SORE    MOUTH. 

Ulcerative  stomatitis  is  characterized  by  fetid  breath,  ulceration  of 
the  gums,  and  profuse  salivation.  It  may  develop  at  any  age  after  the 
eruption  of  the  teeth,  but  is  more  frequently  seen  between  the  third  and 
tenth  year.  It  is  usually  associated  with  lowered  nutrition,  malhygiene, 
and  infection  of  the  mouth  from  any  cause.  It  occasionally  follows  the 
infectious  diseases,  the  germs  of  which  were  formerly  regarded  as  cau- 
sative. It  may  result  from  certain  mineral  poisons,  such  as  lead,  phos- 
phorus and  mercury.  It  was  formerly  quite  common  as  a  result  of  the 
medicinal  administration  of  large  doses  of  the  last-named  drug.  A  not 
uncommon  cause  in  young  infants  in  scorbutus.  Ulcerative  stomatitis 
is  undoubtedly  infectious  and  probably  contagious,  as  it  occurs  endemi- 
cally  among  hospital  and  dispensary  patients  and  among  soldiers  and 
miners  in  barracks  or  camps. 

The  question  of  its  microbic  origin  is  still  in  doubt,  although  two  or- 
ganisms have  been  isolated, — namely,  a  large  fusiform  bacillus,  in  form 
resembling  the  Klebs-Loeffler,  and  a  slender  spirillum  which  suggests  a 
kinship  between  stomatitis  ulcerosa  and  Vincent's  angina. 

Its  occurrence  in  scorbutus  is  suggestive  of  a  probable  etiologic 
factor, — namely,  a  blood  dyscrasia,  in  which  the  local  manifestations  are 
intensified  by  malhygienic  conditions  of  the  mouth,  as  want  of  cleanli- 
ness of  the  teeth  and  tartar  accumulations.  Although  the  lesions  may 
occur  on  any  part  of  the  oral  mucosa,  they  usually  affect  first  the  gums 
of  the  lower  incisors,  where  the  ulceration  may  appear  as  a  dirty  gray 
line  on  the  gum  margin.  The  gums  are  swollen  and  tender  and  bleed 
readily  on  pressure.  The  margins  rise  toward  the  crown  of  the  teeth, 
both  internally  and  externally,  as  the  process  extends  backward  toward 
the  molar.  The  disease  is  usually  unilateral,  but  it  may  be  bilateral  and 
may  involve  the  entire  structures  of  both  jaws.  Later,  the  spongy  gums 
fall  away  from  the  teeth  and  pus  wells  up  in  the  intervening  fissure,  or 


STOMATITIS  211 

burrows  through  the  alveolar  process  with  subsequent  invasion  of  the 
jaw  and  formation  of  sequestra.  The  teeth  may  loosen  in  their  sockets 
and  fall  out.  The  ulcerative  process  may  extend  to  the  buccal  mucosa, 
either  at  its  junction  with  the  gum  or  opposite  the  molar  teeth,  where  it 
appears  as  a  yellow  streak  or  patch  which  Later  breaks  down,  leaving  an 
open  ulcer  with  foul  bottom  and  ragged,  undermined  edges.  The  sub- 
maxillary and  cervical  lymph  nodes  are  swollen  and  tender,  but  rarely 
suppurate.  There  may  be  little  or  no  elevation  of  temperature  in  mild 
cases,  but  with  the  extensive  ulceration  and  necrosis,  systemic  infection 
may  occur  with  fever  and  other  evidences  of  sepsis.  Loss  of  appe- 
tite and  the  painful  condition  of  the  mouth  lessen  the  ingestion  of 
food,  and  nutrition  suffers.  Other  forms,  such  as  herpetic  stomatitis, 
may  accompany  the  ulcerative;  and  neglected  cases  may  result  in 
gangrene. 

Prognosis. — Untreated  ulcerative  stomatitis  may  run  a  more  or  less 
rapidly  destructive  course,  with  extensive  less  of  tissue  and  resultant  de- 
formity, or  death  from  systemic  infection.  No  serious  disease  yields 
more  readily  to  treatment,  and,  if  recognized  early,  may  be  arrested  and 
cured  in  from  five  to  ten  days.  Advanced  cases  in  cachectic  children 
may  tax  the  patience  of  the  physician,  but  recovery,  excepting  loss  of 
teeth  and  slight  deformity  from  loss  of  carious  bone,  may  be  assured  if 
careful  attention  be  given  to  the  details  of  treatment  and  nutrition. 

Treatment. — The  cause  should  be  ascertained,  if  possible,  and  receive 
appropriate  treatment,  as  fruit  juices  and  fresh  vegetables  in  scorbutus, 
sulphuric  acid  and  potassium  iodide  for  plumbism,  and  improved  hy- 
giene and  nutritious  food  for  the  marasmic.  The  removal  or  prompt 
treatment  of  carious  teeth  must  be  attended  to,  with  cleansing  of  the  oral 
cavity  by  antiseptic  irrigations,  such  as  saturated  boric  acid,  potassium 
permanganate  (1:2000),  hydrogen  peroxide  diluted  with  four  times 
its  quantity  of  water,  or,  probably  the  best  of  all,  a  two  per  cent, 
solution  of  potassium  chlorate.  Obstinate  ulcers  may  be  touched  with 
the  solid  nitrate  of  silver,  powdered  sulphur,  or  burnt  alum.  The 
cheeks  should  be  separated  from  the  affected  gum  by  a  pledget  of  gauze, 
frequently  renewed,  to  prevent  extension  to  the  buccal  surface.  For 
internal  administration,  chlorate  of  potash  is  justly  regarded  as  specific 
in  stomatitis  ulcerosa.  It  may  be  given  to  a  child  of  three  years  in  two- 
grain  (0.13  Gm.)  doses  every  two  hours,  well  diluted.  Its  beneficial 
effects  are  frequently  seen  during  the  second  day  in  diminished  fetor  and 
salivation.  The  use  of  this  remedy  must  be  watched,  as  renal  insuffi- 
ciency and  cardiac  depression  may  follow  its  use  in  susceptible  children. 
Scanty  urine  and  cyanosis  are  indications  for  its  discontinuance.  Tinc- 
ture of  iron,  five  to  ten  minims  0.3-0.6  C.e.)  doses,  or  the  aromatic 
sulphuric  acid,  properly  diluted,  four  times  a  day,  may  be  substituted. 

Prophylaxis  consists  in  the  daily  routine  cleansing  of  the  mouth  and 
teeth  of  children.  This  is  all  the  more  necessary  during  sickness  when 
the  secretions  are  perverted,  and  decomposing  debris  accumulates  rap- 
idly.    During  the  administration  of  mercurials,  stomatitis  may  be  pre- 


212  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

cipitated  by  neglect  of  these  precautions  or  by  the  local  irritation  of  a 
jagged,  carious  tooth. 

STOMATITIS  GANGRENOSA — NOMA  OF  THE  FACE  ;    CANCRUM  ORIS. 

Noma  is  the  most  severe  and  fatal  form  of  stomatitis  in  children.  It 
is  fortunately  rare,  occurring  usually  in  the  interval  between  first  and 
second  dentition.  Noma  is  undoubtedly  of  infectious  origin  and  is 
clearly  communicable,  although  its  sporadic  occurrence  is  frequently  re- 
ported. A  number  of  organisms  accompany  its  progress,  among  them  the 
streptococci,  spirilla?  and  Klebs-Loeffler  bacilli,  to  no  one  of  which  may 
its  specific  etiology  be  attributed.  The  gangrenous  character  of  the 
process,  which  is  a  true  necrobiosis,  is  apparently  due  to  a  combination 
of  circumstances,  prominent  among  which  is  lowered  cellular  resistance 
from  malhygiene  and  previous  disease.  It  may  follow  the  acute  exan- 
thems — typhoid  fever,  pertussis,  scurvy,  enteritis,  syphilis,  etc. — and  is 
frequently  preceded  by  ulcerative  stomatitis. 

The  lesion  usually  begins  on  the  lateral  aspect  of  the  gums,  or  buccal 
mucosa  opposite  the  molars,  probably  as  a  result  of  abrasion,  trauma, 
dental  caries,  and  want  of  cleanliness.  It  is  usually  unilateral,  though 
it  may  spread  to  both  sides. 

Attention  is  first  attracted  by  the  gangrenous  odor  of  the  breath, 
followed  by  discovery  of  the  ulcer,  which  spreads  rapidly  and  deeply 
into  the  subjacent  tissue.  The  submaxillary  and  cervical  glands  enlarge, 
the  cheek  is  swollen,  pale  and  tumid,  the  oedema  involving  the  eyelids. 
There  is  remarkable  absence  of  pain  and  the  fever  may  be  slight  in 
the  early  stages,  with  subnormal  temperature  towards  the  close.  The 
drooling  of  ichorous  saliva  is  excessive  and  the  cadaveric  stench  is  inde- 
scribable, as  the  rapid  destruction  proceeds  through  mucosa,  connective 
tissue,  bone,  and  muscle.  By  the  third  day,  sometimes  earlier,  a  red 
spot  appears  on  the  integument  of  the  cheek  which  deepens  in  color  to 
Mue,  purple,  and  black,  rapidly  increasing  in  area  as  the  necrosis  spreads 
■over  the  face,  destroying  every  tissue  in  its  path  until  arrested  by  death 
of  the  child  from  exhaustion.  Rarely  the  disease  is  arrested  by  spon- 
taneous formation  of  a  line  of  demarcation,  whereupon  the  dead  tissues 
slough  away,  the  teeth  fall,  bony  sequestra  are  thrown  off,  and  the  child 
survives  with  frightful  cicatricial  deformity. 

The  diagnosis  from  ulcerative  stomatitis  is  made  by  the  darker  color 
of  the  lesion,  the  rapid  extension  of  the  necrosis,  and  the  tendency  to 
perforation  of  the  cheek. 

Treatment. — The  early  fatality  of  cancrum  oris  makes  prompt  treat- 
ment imperative,  as  in  surgical  procedure  lies  the  only  known  means  of 
arresting  the  necrotic  process.  Upon  the  appearance  of  noma  no  delay 
is  excusable,  as  every  hour  may  represent  extensive  loss  of  tissue.  Dis- 
infectants and  deodorants — as  peroxide  of  hydrogen,  permanganate  of 
potassium,  and  formalin — as  mouth  washes,  may  limit  the  digestive  dis- 
turbance from  infectious  material  swallowed,  and  render  the  atmos- 
phere of  the  sick-room  tolerable  for  the  attendants.     Cases  are  reported 


STOMATITIS  213 

in  which  injections  of  antistreptococcic  and  antidiphtheritic  sera  have 
seemed  to  arrest  the  disease.  Favorable  results  have  recently  been 
claimed  for  the  red-light  treatment.  From  our  present  knowledge,  how- 
ever, the  conscientious  physician  will  not  temporize  with  gangrenous 
stomatitis,  as  prompt  and  thorough  surgery  affords  the  best  known  means 
of  relief. 

From  the  exhausting  nature  of  the  disease,  alcoholic  stimulation  is 
indicated  to  its  fullest  extent,  and  the  heart  should  be  supported  by 
strychnia  and  digitalis.  Concentrated,  easily  digested  foods  are  essen- 
tial for  the  maintenance  of  nutrition.  Rectal  feeding  may  be  necessary 
on  account  of  the  usually  disordered  state  of  the  stomach.  The  highly 
infectious  nature  of  noma  must  not  be  forgotten,  as  its  extension  to 
other  inmates  of  the  house  or  ward,  has  been  known  to  follow  a  lapse  in 
the  strictest  antiseptic  regimen.  Analogous  processes  with  fatal  ter- 
mination have  been  known  to  develop  in  the  external  ear,  nose,  and 
genitals  of  children  from  direct  infection  through  carelessness  of  the 
attendant. 

STOMATITIS    MEMBRANOSA. 

A  pseudomembrane  may  form  in  the  mouth  and  on  the  lips  as  a  result 
of  irritants,  such  as  hot  drinks,  and  also  during  the  course  of  acute  infec- 
tious fevers.     The  most  pronounced  type  is  seen  in  diphtheria. 

These  membranes  are  usually  the  result  of  bacterial  growth  and  are 
frequently  an  extension  forward  of  a  croupous  angina.  In  rare  in- 
stances, membranous  stomatitis  is  primary.  It  may  be  attended  by  con- 
siderable systemic  disturbance,  although  the  lymph-nodes  sometimes 
show  surprisingly  little  involvement.  The  membranes  may  become 
desiccated  and  darkened  from  exposure  to  the  air  and  from  slight  hem- 
orrhages from  fissures  in  the  mucosa.  Under  proper  treatment  they 
disappear  by  attrition  or  in  masses,  leaving  the  mucosa  reddened  and 
sometimes  denuded  of  epithelium. 

The  diagnosis  from  diphtheria  depends  upon  the  absence  of  Klebs- 
Loeffler  bacilli;  from  mycotic  stomatitis,  by  the  absence  of  the  charac- 
teristic thrush  fungus. 

Treatment. — The  treatment  consists  in  soothing  alkaline  antiseptic 
mouth-washes  or  sprays,  such  as  Seder's  solution  (Formula  11)  or  per- 
manganate of  potassium,  1  :  1000. 

GONORRHEAL    STOMATITIS. 

Gonorrheal  infection  of  the  mouth  occasionally  occurs  during  the  in- 
fant's passage  through  the  birth  canal,  or  from  subsequent  exposure 
through  carelessness  of  the  nurse  or  mother. 

Reported  cases  describe  the  lesion  as  yellowish  patches  occurring  on 
portions  of  the  tongue  and  hard  palate  most  liable  to  erosion  which,  in 
all  probability,  must  precede  the  infection  by  the  gonococcus.  There  is 
little  evidence  of  inflammation  or  tenderness,  and  the  pus  formation  is 
limited,  when  compared  with  the  action  of  the  gonococcus   on   other 


214  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

mucous  membranes.  The  diagnosis  is  made  by  the  presence  of  the 
organism  of  Neisser  and  by  the  accompanying  conjunctivitis,  vulvitis, 
or  vaginitis. 

In  the  infant,  gonorrhoea  of  the  mouth  is  more  tractable  than  is  that 
process  in  other  locations,  yielding  readily  to  alkaline  washes  and  weak 
solutions  of  protargol,  which  should  be  used  two  or  three  times  daily. 
In  obstinate  cases  the  patches  should  be  brushed  lightly  with  one  or  two 
per  cent,  solution  of  this  drug. 

Syphilitic  stomatitis  will  be  considered  in  the  chapter  on  that  subject. 


CHAPTER    V 

DISORDERS    OF   THE   DIGESTIVE   SYSTEM— Continued 
THE  THROAT,  PHARYNX,  AND  OESOPHAGUS 

ACUTE   TONSILLITIS 

Acute  tonsillitis  in  childhood  presents  all  the  varieties  seen  in  the 
adult.  The  most  common  forms  are  simple  or  catarrhal;  follicular  or 
lacunar;  croupous  or  non  diphtheritic ;  diphtheritic;  suppurative  or 
phlegmonous  tonsillitis,  and  peritonsillar  abscess. 

Simple  catarrhal  tonsillitis  is  probably  most  frequently  seen  and  is 
the  usual  accompaniment  of  acute  pharyngitis.  It  is  at  times  epidemic, 
presumably  infectious,  and  may  accompany  most  of  the  acute  infectious 
diseases  of  childhood.  Like  all  acute  catarrhal  inflammations  it  is  pre- 
cipitated by  exposure  to  dampness  and  cold.  The  vitiated  air  of  badly 
ventilated  homes  and  school-rooms  appears  to  excite  it.  It  may  vary  in 
intensity  from  the  transient  sore  throat  of  a  day,  with  little  or  no  indis- 
position, to  a  severe  constitutional  seizure  with  rise  of  temperature, 
headache,  anorexia,  general  malaise,  and  difficult  deglutition. 

Constipation  and  lowered  vitality  are  frequent  precursory  condi- 
tions. Some  children  and  families  show  a  predisposition  to  catarrhal  in- 
flammation of  the  tonsils.  It  is  frequently  associated  with  acute  or 
chronic  inflammation  of  the  rhinopharyngeal  tract.  The  susceptibility 
to  tonsillitis  in  rheumatism  is  referred  to  in  the  description  of  that 
disease. 

In  simple  tonsillitis  the  mucous  membrane  is  congested,  although  the 
tonsils  usually  show  but  moderate  enlargement,  unless  chronically  hyper- 
trophied.  The  adjacent  mucosa  shares  the  vascular  engorgement.  The 
tongue  is  coated  and  the  upper  deep  cervical  glands  may  be  enlarged. 
In  the  first  twenty-four  hours  the  temperature  may  reach  104°  F. 
(40°  C),  and  may  as  suddenly  fall.  An  uncomplicated  case  of  moderate 
severity  will  subside  in  three  or  four  days  with  no  other  treatment  than 
rest  in  bed. 

Treatment. — The  treatment  consists  in  free  catharsis,  keeping  the 
child  quiet,  and  the  use  of  a  mild  antiseptic  gargle  or  spray  (Formula 
11)  every  two  or  three  hours.  If  deglutition  be  painful,  cracked  ice  may 
be  put  in  the  mouth  to  relieve  the  thirst.  The  diet  should  be  light, 
consisting  of  milk  and  other  liquids. 

The  chief  interest  in  the  condition  attaches  to  the  possibility  of  the 
later  development  of  other  infections,  as  diphtheria,  which  is  favored 
by  the  lowered  vitality  and  abnormal  condition  of  the  mucosa. 

215 


216  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

SUPPURATIVE    TONSILLITIS — PLEGMONOUS    TONSILLITIS;     QUINSY. 

This  form  of  tonsillitis,  although  infrequent  in  infancy,  is  often  seen 
in  later  childhood  and  pubescence.  Occasionally,  instead  of  complete 
subsidence  of  the  more  acute  symptoms  of  simple  catarrhal  tonsillitis, 
the  fever,  malaise  and  intense  local  hyperemia  may  improve  but  the  ton- 
sils remain  somewhat  swollen.  After  an  interval  of  a  day  or  two,  fol- 
lowing a  second  exposure  to  cold,  one  or  the  other  tonsil  again  becomes 
painful.  The  child  has  chilly  sensations  followed  by  a  rise  in  tem- 
perature, deglutition  becomes  extremely  difficult  and  the  jaws  may  be 
separated  but  slightly  and  with  great  pain.  The  tongue  is  foul,  the  breath 
fetid,  sordes  collect  on  the  teeth,  and  the  throat  is  harassed  by  tenacious 
secretion  which  can  neither  be  swallowed  nor  expectorated,  on  account  of 
the  pain  on  the  least  movement  of  the  muscles  of  the  jaw.  Pain  radi- 
ating to  the  ear  is  complained  of,  and  otitis  media  is  not  an  uncommon 
complication  by  direct  infection  through  the  Eustachian  tube.  There 
may  be  torticollis.  The  voice  is  non-resonant,  as  if  the  throat  were  full 
of  food. 

If  the  rigid  jaw  will  permit,  the  palpating  finger  may  outline  the 
considerably  enlarged  tonsil  as  a  more  or  less  firm,  boggy,  or  elastic 
mass,  extremely  sensitive  to  touch.  The  effects  of  pain,  loss  of  sleep, 
and  want  of  nourishment,  soon  show  in  the  weakened  condition  and  hag- 
gard appearance  of  the  child.  The  swelling  and  evidences  of  toxaemia 
may  continue  from  three  to  six  days,  when  there  is  sudden  disappearance 
of  the  distressing  symptoms  from  spontaneous  rupture  and  discharge 
of  the  tonsillar  abscess.  This  collection  of  pus  may  be  in  the  substance 
of  the  tonsil,  in  the  peritonsillar  tissue,  or,  having  started  in  either 
place,  may  invade  the  other.  Evacuation  of  the  pus  is  immediately  fol- 
lowed by  subsidence  of  the  swelling  and  usually  by  rapid  convalescence. 
Occasionally,  however,  the  opposite  tonsil  takes  on  active  inflammation 
and  the  history  of  phlegmonous  tonsillitis  is  repeated. 

The  prognosis,  as  to  life,  is  favorable  with  the  rare  exception  of  acci- 
dental death  from  hemorrhage  or  suffocation.  The  former  may  follow 
erosion  of  the  carotids  by  burrowing  of  the  tonsillar  abscess.  Suffoca- 
tion may  be  caused  by  aspiration  of  pus  discharged  during  sleep,  by 
oedema  of  the  glottis  from  extension  of  the  inflammation,  or  by  an  enor- 
mously distended  tonsil.  In  the  narrow  pharynx  of  the  young  child, 
obstruction  to  respiration  may  arise  to  such  an  extent  as  to  render 
tracheotomy  imperative.  In  all  cases  of  tonsillitis  in  children  rheu- 
matic endocarditis  should  never  be  forgotten,  and  the  heart  should  receive 
daily  examination.  Very  commonly,  with  or  without  continuation  of 
fever,  an  apical  murmur  may  develop,  and  the  area  of  dulness  may  be 
found  extending  beyond  the  nipple. 

Xot  only  the  possibility  of  these  accidents  but  the  distressing  pain 
emphasizes  the  importance  of  early  evacuation  of  the  abscess.  This  in 
the  struggling  child  is  by  no  means  a  trivial  or  easy  operation.  The 
patient  must  be  wrapped  in  a  blanket  and  held  by  the  assistant  as  for 


TONSILLITIS  217 

intubation;  a  strong  tongue  depressor  is  forced  into  the  mouth  and 
the  jaw  depressed  so  that  the  bistoury,  guarded  to  the  Last  quarter  inch 
by  adhesive  plaster,  may  be  introduced.  A  cut  of  one-half  inch  may  be 
made  toward  the  median  line.  Even  if  the  abscess  be  not  reached  relief 
is  afforded  by  the  local  bleeding,  and  the  pus  discharge  may  follow 
later,  having  a  less  distance  to  burrow. 

Preceding  this,  however,  relief  may  be  afforded  by  spraying  the  mouth 
and  fauces  with  an  antiseptic  alkaline  solution  (Formula  12)  for  the 
removal  of  tenacious  and  decomposing  secretions.  In  older  children  cau- 
tious spraying  of  the  nasopharynx  may  cleanse  that  cavity  of  much  in- 
fectious material.  Care  must  be  observed,  by  limiting  the  quantity,  not 
to  force  fluids  into  the  Eustachian  tube.  The  nasal  passage  may  also  be 
used  for  liquid  feeding  through  the  small  stomach  tube.  Pieces  of  ice 
may  be  swallowed  to  diminish  thirst  and  local  hyperemia  when  there 
is  great  dysphagia.  In  the  same  way  ice  cream  may  be  tolerated  because 
of  the  analgesic  effect  of  cold.  Expressed  raw  meat  juice  may  be  mixed 
with  the  cream  before  freezing.  For  extreme  pain  Dover's  powder, 
one-half  to  one  grain  (0.03-0.065  Gm.),  may  be  necessary.  In  the  de- 
veloping stage  the  astringent  effect  of  iron,  preferably  the  tincture  of  the 
chloride  diluted  with  three  to  six  parts  of  glycerine,  applied  directly  to 
the  tonsil,  tends  to  limit  the  extent  of  the  inflammation.  Some  cases 
may  be  aborted  if  treated  promptly  by  the  application  to  the  inflamed 
tonsil  of  a  drop  or  two  of  guaiacol  on  a  pledget  of  cotton  held  in  the 
grip  of  long  forceps. 

The  free  use  of  calomel,  one  to  four  grains  (0.065-0.26  Gm.)  accord- 
ing to  age,  is  recommended  in  the  early  stage.  This  may  be  followed  by 
smaller  doses  at  intervals  of  four  hours  throughout  the  attack.  Occa- 
sionally it  may  be  administered  dry  upon  the  tongue,  combined  with 
sodium  bicarbonate.  The  intense  congestion  may  be  somewhat  dimin- 
ished by  hot  pediluvia  and  the  application  of  hot  poultices  to  the  neck. 
Small  ice  bags  applied  to  the  angle  of  the  jaw  are  also  useful  if  well 
borne.  The  child  should  be  kept  in  bed,  and  when  rupture  of  a  large 
abscess  is  threatened  he  should  be  propped  in  the  sitting  position, 
so  that  a  sudden  discharge  may  find  free  exit  through  the  mouth. 

FOLLICULAR    TONSILLITIS — LACUNAR    TONSILLITIS. 

Follicular  tonsillitis  is  common  in  childhood,  and  is  probably  not  so 
rare  in  early  infancy  as  formerly  was  supposed.  A  routine  practice 
of  throat  examination  in  all  febrile  disturbances  in  early  life  will,  un- 
doubtedly, reveal  tonsillar  inflammation  in  cases  where  pain  in  the 
throat  is  not  a  marked  symptom.  In  this  variety,  not  only  may  the 
superficial  surface  of  the  tonsils  and  adjacent  mucosa  be  involved  in  a 
catarrhal  inflammation,  but  the  tonsillar  crypts  or  follicles — and  fre- 
quently those  of  the  posterior  pharyngeal  wall — seem  specially  selected 
in  the  inflammatory  process. 

The  evidences  of  infectiousness  and  communicability  are  beyond  ques- 
tion.    It  often  attacks  different  members  of  a  family  in  quick  succes- 


218  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

sion.  Any  or  several  of  the  various  resident  bacteria  may  be  found  in 
increased  numbers  and  activity.  Exposure  to  the  cold,  damp  weather  of 
the  winter  and  early  spring  is  recognized  as  an  exciting  cause,  and  local 
epidemics  at  this  time  are  of  frequent  occurrence.  Rheumatic  children 
show  a  decided  predisposition  to  this  affection.  Its  favorite  seat  is  in 
tonsils  chronically  hypertrophied,  so  that  liability  to  follicular  tonsil- 
litis increases  with  repetition  of  attacks. 

The  attack  in  older  children  occasionally  begins  with  a  chill,  though 
vomiting  is  more  often  seen  in  infants.  The  temperature  may  range 
from  101°  to  105°  F.  (38.5°-40.5°  C),  with  the  usual  constitutional  symp- 
toms. Constipation  is  common  at  the  beginning,  though  in  babies, 
diarrhoea  with  green  stools  may  quickly  follow,  possibly  from  the  swal- 
lowing of  the  infected  mucus.  In  fact,  tonsillitis  in  infants  may  be 
overlooked  in  the  treatment  of  a  gastro-enteritis.  There  may  be  a  slight 
enlargement  and  tenderness  of  the  lymphatic  glands  at  the  angles  of  the 
lower  jaw.  A  view  of  the  throat  shows  a  reddened  mucosa,  especially 
over  the  tonsils,  which  are  somewhat  enlarged  and  contain  one  or  more 
yellowish- white  pinhead  spots,  on  one  or  both  tonsils,  marking  the  mouths 
of  the  crypts.  These  exudative  spots  project  slightly  from  the  surface 
of  the  tonsil  and  represent  the  visible  portion  of  the  inflammatory  debris 
with  which  the  crypt  is  distended.  This  mass  consists  of  exfoliated 
epithelium,  bacteria  (principally  cocci),  exudative  lymph,  and,  in  some 
cases,  fibrin  in  agglutination  varying  from  semisolid  in  acute  tonsillitis 
to  "cheesy"  consistency  in  chronic  cases.  As  the  inflammation  advances 
other  follicles  extrude  their  contents  until  the  exudation  assumes  a 
punctate  appearance,  with  a  tendency  to  rapid  coalescence. 

The  temperature  may  be  remittent  in  character,  showing  evening 
exacerbations  for  two  to  five  days.  There  is  usually  sensitiveness  of 
the  throat  with  painful  deglutition.  The  tonsillar  patches  may  disap- 
pear with  the  subsidence  of  the  fever,  but  often  persist  for  several 
days.  Slight  permanent  tonsillar  hypertrophy  is  the  rule,  and  this  is 
augmented  with  each  succeeding  attack. 

In  the  beginning,  the  diagnosis  from  catarrhal  tonsillitis  is  impos- 
sible, and  can  only  be  made  later  with  the  appearance  of  the  plugs  in 
the  crypts.  After  coalescence,  the  diagnosis  from  the  membranous 
form  may  be  difficult  and  depends  largely  upon  the  non-extension  of  the 
membrane  to  the  uvula,  velum,  or  faucial  pillars.  From  diphtheria, 
which  should  always  be  suspected  until  disproved,  the  culture  test  is  the 
only  positive  means  of  differentiation. 

The  prognosis,  if  uncomplicated,  is  favorable. 

Diphtheria,  peritonsillar  abscess,  endocarditis,  otitis,  hypertrophied 
tonsils  and  adenoids  are  among  the  complications  and  sequela?. 

Treatment. — The  treatment  consists  in  free  catharsis  by  calomel,  ipe- 
cac and  soda,  and  in  local  applications  of  alkaline  and  antiseptic  sprays, 
as  Seller's  or  Dobell's  solution.  In  view  of  possible  diphtheritic  infec- 
tion or  invasion  of  the  deeper  tonsillar  structures,  a  drop  or  two  of  pure 
liquid  guaiacol  may  be  applied  on  a  small  compressed  pledget  of  cotton 


TONSILLITIS  219 

to  the  affected  areas.  The  smarting  caused  by  the  application  is  imme- 
diately followed  by  local  analgesia.  The  deep  penetrability  of  this  anti- 
septic agent  is  well  proven.  Tincture  of  iron,  ten  per  cent.,  in  glycerin, 
may  be  used  as  a  gargle  or  spray,  or  swallowed,  in  half  teaspoonful  doses, 
three  or  four  times  a  day,  both  for  its  local  astringent  and  general  restor- 
ative effect.  In  rheumatic  eases  sodium  salicylate,  two  to  ten  grains 
(0.13-0.65  Gm.j  with  an  equal  quantity  of  sodium  bicarbonate,  should 
be  administered  every  two  or  three  hours  to  avoid  heart  complication. 
Bromide  of  sodium  and  ammonium  may  be  given  by  mouth  or  rectum 
for  extreme  restlessness.  High  temperature  calls  for  tepid  bathing. 
Applications  to  the  neck  of  cold  or  heat,  as  found  most  agreeable,  may 
conduce  to  the  child's  comfort. 

The  management  of  convalescence  by  proper  nutrition  and  tonics 
should  never  be  neglected. 

Pseudomembranous  tonsillitis,  as  it  occurs  in  diphtheria  and  the 
exanthemata,  is  discussed  under  the  specific  diseases  with  which  it  is 
associated. 

CHRONIC    TONSILLITIS — HYPERTROPHY    OF   THE   TONSILS. 

Hypertrophy  of  the  tonsils  may  develop  at  any  period  of  childhood 
and  it  is  occasionally  congenital.  Many  children  show  an  hereditary 
predisposition  to  enlargement  of  the  tonsils,  in  common  with  hypertrophy 
of  lymphoid  tissue  in  other  regions.  This  constitutes  a  prominent  fea- 
ture of  lymphatism.  Adenoid  vegetations  in  the  nasopharynx  often 
accompany  and  frequently  act  as  an  exciting  cause  for  hypertrophy  of 
the  faucial  tonsils.  Among  the  pernicious  effects  of  obstruction  of  the 
upper  respiratory  tract,  mouth-breathing  has  been  mentioned.  This 
compensatory  habit  induces  faucial  irritation  from  the  constant  current 
of  unwarmed,  unmoistened,  and  unfiltered  air,  which  in  the  child  pre- 
disposed to  lymphoid  hypertrophy,  quickly  results  in  enlargement  of  the 
tonsils.  The  rheumatic  diathesis,  also,  predisposes  to  tonsillar  enlarge- 
ment, usually  as  a  result  of  repeated  attacks  of  pharyngeal  inflammation. 
Many  cases,  however,  are  seen  with  no  history  of  acute  tonsillitis.  In 
addition  to  diathetic  predisposition,  climate  exerts  a  positive  influence  in 
the  production  of  these  overgrowths.  In  this  country  they  are  more 
common  along  the  Atlantic  coast  and  the  Great  Lakes  region,  where  sud- 
den changes  in  temperature  and  humidity  are  prevalent, 

In  infancy  the  enlargement  is  principally  an  increase  in  the  lymphoid 
tissue,  the  tonsils  remaining  soft.  In  older  children  there  is  increase, 
also,  in  the  connective  tissue,  the  enlarged  tonsils  showing  sclerotic 
changes,  with  compression  of  the  follicles,  deeper  Assuring,  and  occasional 
deposition  of  calcareous  material.  The  degree  of  enlargement  and  the 
effects  upon  the  child  differ  widely.  Deglutition  is  rarely  interfered 
with,  except  during  acute  exacerbations. 

Marked  tonsillar  hypertrophy  gives  a  peculiar  quality  to  the  voice. 
It  sounds  as  though  the  throat  were  full  of  soft  food,  and  articulation  is 
indistinct,    Snoring  in  sleep  may  result  through  relaxation  of  the  velum 


220  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

palati.  In  rare  cases  extreme  hypertrophy  may  interfere  with  the  free 
ingress  of  air  through  the  diminished  lumen  of  the  pharynx,  or  from 
downward  pressure  upon  the  epiglottis.  This  condition,  if  it  persist, 
will  produce  the  same  defects  that  are  seen  in  chronic  obstruction  from 
hypertrophic  rhinitis  or  adenoid  vegetations  in  the  nasopharynx.  The 
deafness  attributed  to  enlarged  tonsils  is  more  often  due  to  the  accom- 
panying adenoids. 

The  interference  with  phonation,  when  occurring  in  early  infancy, 
probably  retards  the  development  of  speech.  The  retained  secretions, 
by  reason  of  tonsillar  enlargement,  favor  decomposition  and  cause  fetor 
of  the  breath.  The  swallowing  of  the  secretion,  which  is  increased  in 
quantity,  is  productive  of  digestive  disturbance  and  resultant  impair- 
ment of  nutrition.  In  addition  to  this  the  broken  sleep  intensifies  the 
malnutrition  and  induces  a  great  variety  of  nervous  symptoms. 

Although  hypertrophied  tonsils  rarely  threaten  life,  their  presence 
furnishes  favorable  cultural  conditions  for  a  variety  of  infections.  This 
is  especially  true  of  diphtheria. 

Slight  tonsillar  hypertrophy  may  gradually  disappear  after  pu- 
berty without  treatment.  No  case  should  be  neglected,  especially  in 
infancy  and  early  childhood,  on  account  of  the  handicap  to  development, 
and  the  tendency  of  the  morbid  condition  to  increase.  Some  of  the  ill 
effects  may  be  minimized  by  keeping  the  mouth  and  throat  clean  by  the 
use  of  gargles  and  sprays.  The  last  may  best  reach  the  posterior  portion 
of  the  tonsil  through  the  nasal  passages.  The  tonsils  may  be  painted 
daily  with  tincture  of  chloride  of  iron,  pure  or  diluted  with  three  parts 
of  glycerin,  or  occasionally  with  tincture  of  iodine  or  five  per  cent,  solu- 
tion of  nitrate  of  silver. 

Constitutional  treatment  for  malnutrition  and  lymphatism,  such  as 
outdoor  exercise,  cool  bathing,  cod-liver  oil,  and  syrup  of  the  iodide  of 
iron,  should  be  adopted. 

Undoubtedly  the  best  treatment,  when  the  tonsil  is  sufficiently  large 
to  interfere  with  normal  functions,  is  amputation.  The  mucosa  should 
be  cleansed  and  rendered  less  sensitive  by  a  course  of  gargling  or  atom- 
ization  of  a  solution  of  boric  acid  and  potassium  bromide  for  a  few 
days  prior  to  the  operation  (Formula  16).  The  glands  should  be  en- 
tirely removed,  as  any  portion  left  favors  redevelopment. 

No  objection  to  the  removal  of  enlarged  tonsils  is  recognized,  save 
the  possibility  of  infection  or  troublesome  hemorrhage.  The  presence  of 
acute  inflammation  or  a  history  of  hemonhilia  contraindicates  the  opera- 
tion. An  astringent  gargle,  as  a  two  per  cent,  solution  of  alum,  should  be 
used  after  amputation.  The  result  of  tonsillotomy  is  sometimes  disap- 
pointing from  failure  to  recognize  that  faulty  habits  of  respiration  and 
speech  must  be  overcome  by  patient  and  persistent  training. 

VINCENT 'S    ANGINA — ULCEROMEMBRANOUS    TONSILLITIS. 

This  disease  appears  as  a  tonsillitis,  pharyngitis,  or  stomatitis.  It 
is  caused  by  a  needle-shaped  bacillus  which  is  usually  associated  with  a 


TONSILLITIS  221 

spirillum.  This  spirillum,  identical  with  that  found  in  carious  teeth, 
was  first  described  by  Vincent,  in  1896,  ;is  the  cause  of  ulcero-mem- 
branous  angina.  This  organism  is  commonly  present  in  the  deeper 
layers,  although  its  share  in  the  etiology  of  this  disease  is  still  ques- 
tioned. Among  the  predisposing  causes  are  lymphatism,  syphilis,  erup- 
tion of  teeth,  carious  teeth,  and  malhygiene  of  the  mouth.  The  disease  is 
communicable,  small  epidemics  having  been  reported.  The  affection  of 
the  tonsils  is  often  preceded  by  similar  lesions  in  the  mouth  and  pharynx. 

The  chief  characteristic  is  a  greasy,  friable,  diphtheroid  pseudomem- 
brane,  which  may  be  unilateral  or  involve  both  sides  by  extension. 
Within  thirty-six  hours  ulceration  occurs  in  the  tonsil.  The  ulcers  may 
be  quite  extensive  and  present  the  punehed-out  margin  and  foul  base  of 
the  chancroid.  The  breath  is  offensive  with  a  characteristic  fetor.  Sali- 
vation is  marked  and  deglutition  is  painful.  The  lymph  nodes  at  the 
angle  of  the  jaw  are  hard  and  tender,  although  periglandular  oedema  is 
absent.  There  is  little  evidence  of  constitutional  involvement.  Fever  is 
often  slight,  compared  with  the  extent  of  the  local  lesion. 

Diagnosis. — Vincent's  angina  is  to  be  diagnosed  from  diphtheritic, 
follicular  and  syphilitic  sore  throat,  each  of  which  it  may  accompany  and 
intensify  by  symbiosis.  It  should  be  stated,  however,  that  the  presence 
of  Vincent's  spirillum  in  the  secretions  of  the  throat  is  said  to  preclude 
diphtheria.  The  chief  points  in  differentiation  are  the  extreme  fetor 
of  the  breath  and  the  slight  constitutional  disturbance,  as  compared  with 
the  fever  and  malaise  of  follicular  tonsillitis.  The  hard,  nodular  adenitis 
is  found  instead  of  the  periglandular  swelling  of  diphtheria.  The  greasy 
friability  of  the  membrane — which  may  be  partially  wiped  off — is  in 
contrast  with  the  firm  adherence  of  the  diphtheritic  exudate,  and  the 
absence  of  paralyses  with  post-diphtheritic  neuritis.  The  short  duration 
of  the  disease  and  its  amenability  to  treatment,  differ  from  the  obstinacy 
of  syphilitic  lesions.  The  main  diagnostic  point,  however,  is  the  presence 
of  the  bacillus  and  spirillum  of  Vincent. 

The  prognosis  is  favorable,  as  the  lesions  yield  readily  to  treatment. 

The  treatment  is  principally  local,  in  which  two  drugs  are  advocated 
as  specifics, — viz.,  menthylene-blue  applied  in  powdered  form  to  the 
lesions,  and  potassium  chlorate,  locally  and  internally,  its  local  effects 
being  secured  secondarily  through  its  elimination  by  the  salivary  glands. 
The  quantity  of  the  latter  drug  in  twenty-four  hours  may  vary,  accord- 
ing to  age,  from  ten  to  thirty  grains  (0.65-1.95  Gm.)  in  broken  doses. 
Most  of  the  antiseptic  sprays  and  gargles,  from  boric  acid  solution  to 
hydrogen  peroxide,  have  been  recommended.  The  ulcers,  if  extensive 
or  foul,  may  be  touched  with  nitrate  of  silver,  tincture  of  the  chloride 
of  iron,  or  iodine.  In  young  children  the  objection  to  topical  application 
is  so  obvious  that  the  internal  use  of  potassium  chlorate  and  milder  gar- 
gles or  sprays  are  preferable  in  a  disease  presenting  little  evidence  of 
general  intoxication. 

The  contagious  character  and  the  possibility  of  diphtheria  require 
prompt  isolation  in  every  case. 


222  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

ACUTE  UVULITIS. 

The  uvula  may  share  in  the  inflammation  of  acute  pharyngitis,  or  it 
alone  may  be  the  seat  of  the  attack.  The  mucous  membrane  is  reddened 
and  cedematous  and  the  uvula  swollen  to  double  its  normal  size.  Trou- 
blesome cough  is  the  most  obvious  symptom  and  there  may  be  slight 
fever. 

Treatment  consists  in  the  application  of  mild  astringents,  as  alum  or 
tannin  solutions;    also  ice  internally  and  externally. 

Elongation  of  the  uvula  may  be  congenital  but  is  more  frequently  the 
result  of  uvulitis.  The  uvula  drags  upon  the  base  of  the  tongue  and 
causes  an  irritating  cough  and  constant  attempts  at  swallowing.  It  may 
cause  vomiting.  Astringent  applications  may  reduce  the  elongation,  or 
the  tip  of  the  uvula  may  be  amputated.  If  bleeding  be  troublesome  the 
cut  surface  should  be  touched  with  solid  silver  nitrate,  or  Monsel's  solu- 
tion of  iron. 

PHARYNGITIS.  . 

The  history  of  a  child  without  an  attack  of  pharyngitis  would  be  a 
rarity.  With  the  exception  of  rhinitis  no  disorder  is  so  common  in  in- 
fancy and  childhood.  Although  it  may  present  many  varieties  as  to 
extent,  and  degree  of  severity,  it  will  be  discussed  under  two  forms, — 
namely,  acute  and  chronic  pharyngitis. 

ACUTE   PHARYNGITIS. 

Etiology. — Catarrhal  inflammation  of  the  pharyngeal  mucosa  rarely 
occurs  independently  of  lesions  of  contiguous  mucous  tracts.  Like  them, 
it  is  probably  due  to  infection.  Among  the  predisposing  causes,  such  as 
heredity,  lowered  nutrition,  and  exposure  to  cold  and  dampness,  infancy 
itself  is  undoubtedly  the  most  important.  The  period  of  rapid  develop- 
ment is  characterized  by  an  abundance  and  hyperactivity  of  lymphoid 
tissue.  This  activity,  in  the  highly  vascular  and  loosely  attached  mucosas,, 
invites  the  easily  induced  congestion.  The  tendency  to  these  catarrhal 
inflammations  is  in  direct  ratio  to  the  degree  of  lymphatism  of  the  indi- 
vidual child.  Impoverished  nutrition,  syphilis,  and  rheumatism  furnish 
opportunity  which  exposure  to  cold,  damp,  overheated,  foul,  or  other- 
wise irritating  atmosphere,  further  renders  favorable  for  infection  of 
the  mucous  membrane  by  the  resident  bacteria. 

Symptoms. — The  common  symptoms  are  a  feeling  of  dryness  and 
smarting  in  the  throat  and  pharynx,  intensified  by  breathing  cold  or 
contaminated  air,  with  a  frequent  irrepressible  desire  to  clear  the  throat 
or  cough.  There  is  usually  a  rise  of  temperature,  100°  to  103°  F.  (37.8°- 
39.5°  C. ) ,  which  may  have  been  preceded  by  vomiting  or  chill.  The  usual 
febrile  accompaniments — malaise,  anorexia,  headache,  foul  tongue,  and 
feverish  breath — are  present,  and  there  is  painful  deglutition,  not  al- 
ways proportionate,  however,  to  the  extent  of  the  inflammation.  Tender- 
ness and  pain  at  the  angle  of  the  jaw  and  glandular  enlargement  are 
common. 


PHARYNGITIS  223 

The  throat,  when  examined  at  the  inception,  appears  red  and 
dry.  A  few  hours  later  the  mucous  membrane  is  covered  with  a  glis- 
tening', tenacious  secretion.  The  inflammation  may  involve  all  the 
visible  portions,  the  fauces,  pillars,  uvula,  and  pharyngeal  wall,  or 
it  may  be  conlined  to  the  latter  surface.  The  erythema  may  be  in 
streaks  or  patches  with  normal  membrane  between.  Again,  it 
may  present  a  punctate  appearance  with  bright  red  papilla;  showing 
through  the  secretion  which  covers  the  duller  red  of  the  surrounding 
parts. 

Rhinitis,  tonsillitis,  laryngitis,  one  or  all,  may  accompany  the  pharyn- 
geal inflammation.  Cough,  frequently  attributed  to  a  bronchitis,  may 
be  due  solely  to  the  pharyngeal  disturbance.  Various  forms  of  stoma- 
titis may  precede  or  accompany  a  pharyngitis  and  modify  the  pharyn- 
geal lesion.  Herpetic  lesions  are  seen  implanted  on  the  pharyngeal 
wall,  or  the  follicles  which  stud  the  mucosa  may  appear  turgid  and  even 
cedematous, — a  form  of  inflammation  to  which  the  term  follicular  pharyn- 
gitis is  applied. 

In  uncomplicated  simple  pharyngitis  the  temperature  subsides  in  a 
few  days  and  the  soreness  and  redness  disappear.  A  week's  time  may 
show  the  tissue  in  an  apparently  normal  condition. 

Diagnosis. — The  diagnosis  of  pharyngitis  refers  to  its  proper  inter- 
pretation rather  than  to  the  existence  of  the  lesion,  and  is  especially  im- 
portant, since  much  may  depend  upon  an  early  recognition  of  associated 
disorders.  Occasionally,  pharyngitis  may  be  an  indication  of  digestive 
disorders  and  yields  to  their  correction.  It  may  be  an  expression  of 
rheumatism,  and,  recognized  as  such,  should  put  the  physician  on  the 
alert  for  cardiac  complications.  Associated  arthritic  and  muscular  symp- 
toms should  be  looked  for. 

Rheumatic  pharyngitis  is  characterized  by  sudden  onset,  pain  out  of 
proportion  to  the  apparent  congestion,  and  often  abrupt  disappearance 
of  all  symptoms. 

Quite  frequently  pharyngeal  inflammation  heralds  the  onset  of  the 
acute  infections,  such  as  scarlet  fever,  measles,  variola  and  diphtheria, 
in  which  differentiation  may  be  made  by  the  character  of  the  throat 
lesions  and  accompanying  symptoms, — e.g.,  mottled  throat  and  Koplik's 
spots  of  measles,  the  intense  diffuse  redness  of  scarlet  fever,  and  the 
discrete  papillary  eruption  of  variola,  or  the  appearance  of  pseudomem- 
brane  upon  the  mucosa,  which  should  give  warning  of  its  true  nature, 
and  lead  to  prompt  isolation  of  the  patient.  Syphilis  and  tuberculosis 
are  rare  factors  in  the  pharyngitis  of  early  childhood. 

The  prognosis  depends  upon  the  cause. 

Treatment. — The  treatment  of  simple  acute  pharyngitis  requires  rest 
in  bed  for  two  or  three  days,  free  evacuation  of  the  bowels,  cold  com- 
press to  the  neck,  gargles  or  sprays  of  alkaline,  antiseptic  solutions  (For- 
mula 11).  Spraying  through  the  nares,  when  the  posterior  wall  is  the 
only  part  involved,  is  a  most  efficient  method.  Cold  demulcent  drinks,  as 
flaxseed  tea  or  iced  slippery-elm  water,  or  swallowing  bits  of  ice,  afford 


224  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

comfort  and  relieve  the  congestion.  Pain  in  the  ear  is  common,  but  otitis 
media  may  develop  without  pain.  Heat  applied  to  the  ear  gives  relief. 
The  ear-drum  should  be  examined  frequently  for  evidences  of  suppu- 
ration. 

CHRONIC    PHARYNGITIS. 

Repeated  attacks  of  pharyngitis  tend  to  hypertrophy  of  the  struc- 
tures of  the  lymphoid  ring.  The  posterior  pharyngeal  wall,  in  the 
chronic  state,  presents  a  persistent  hyperemia  with  irregular  masses 
of  elevated  tissue,  varying  in  size  from  a  pinhead  to  a  pea. 

The  surface  may  be  dry  or  may  be  covered  with  a  tenacious  secre- 
tion which  extends  downward  from  the  vault.  This  chronic  form  of 
pharyngitis  is  not  common  in  early  childhood. 

There  is  a  feeling  of  dryness  in  the  throat  and  a  frequent  cough, 
hawking,  or  screatus,  to  remove  the  viscid  mucus  extruded  from  the 
hypertrophied  follicles.  This  condition,  accompanied  by  enlarged  Lusch- 
ka's  tonsil  and  hypertrophic  rhinitis,  is  not  infrequent  in  later  child- 
hood, especially  in  the  catarrhal  regions  of  the  Great  Lakes  and  Atlantic 
seaboard,  where  sudden  changes  of  temperature  are  frequent. 

The  fetid  breath,  constant  hawking  to  dislodge  the  tenacious  secretion, 
the  impaired  resonance  of  the  voice,  and  the  snuffling  or  snoring  respira- 
tion during  sleep,  all  mark  the  victim  of  chronic  pharyngeal  catarrh. 

The  treatment  of  chronic  follicular  pharyngitis  is  the  same  as  that 
of  allied  conditions  in  the  nasal  and  tonsillar  mucosa.  Benefit  may  be 
derived  from  the  application  of  astringents,  as  tincture  of  iodine,  two 
per  cent,  solution  of  nitrate  of  silver,  and  bland,  oily  atomization.  The 
indications  for  improvement  of  the  general  health  by  diet,  outdoor 
exercise,  and  judicious  use  of  tonics  and  attention  to  hygiene,  should 
never  be  overlooked.  The  removal  of  tonsillar  and  nasopharyngeal 
growths  should  not  be  neglected.  In  obstinate  cases,  removal  to  a  salu- 
brious climate  may  be  necessary  for  complete  cure. 

In  rheumatic  children,  alkaline  waters  and  the  salicylates  are  valu- 
able to  intercept  acute  attacks  and  to  lessen  the  tendency  to  chronicity 
of  pharyngeal  inflammation. 

The  syphilitic  dyscrasia  should  be  kept  in  mind.  Occasional  courses 
of  potassium  iodide,  alternating  with  the  iodide  of  iron,  have  proved 
beneficial  in  some  chronic  cases  of  doubtful  etiology. 

ADENOID   VEGETATIONS. 

Hyperplasias  of  the  pharyngeal  lymphoid  tissues,  first  recognized  by 
Czerniak  in  1860,  were  called  adenoid  vegetations  by  Meyer,  of  Copen- 
hagen, who  first  described  them  in  1868. 

With  the  possible  exception  of  rhachitis  and  lymphatism,  with  which 
they  are  frequently  associated,  there  is  probably  no  common  condition 
of  childhood  of  more  serious  import  than  adenoids.  The  immediate  and 
remote  influences,  not  only  upon  the  nutrition  and  growth  of  the  child, 
but  upon  his  susceptibility  to  infections  and  his  resistance  to  disease, 


ADENOIDS 


225 


bear  an  important  relation  to  the  morbidity  and  mortality  of  the  develop- 
ing period. 

From  the  mass  of  accumulating  evidence  it  is  apparent  that  the 
profession  is  finally  awakening  to  the  importance  of  this  relatively  com- 
mon affection. 

Adenoids  consist  of  nodules  of  hyperplastic  pharyngeal  lymphoid 
tissue  grouped  into  masses  and  covered  with  ciliated  epithelium.  They 
are  the  result  of  an  overgrowth  of  lymphoid  tissue  normally  found  in 
the  pharyngeal  vault.  They  appear  closely  related  to  the  tonsils  in 
structure  and  function,  and  the  mass  is  known  as  the  third,  or  Luschka's 
tonsil.  They  differ  from  the  tonsils,  however,  in  the  variety  of  forms 
of  arrangement  of  their  nodular  masses,  which  may  be  broad,  sessile, 
pedunculated;    cauliflower,  stalactite,  or  coxcomb;    firm  in  texture  or 

friable.  From  the  vault  they  may 
extend  forward  to  the  choanae  of 
the  nose,  or  backward  to  the  lower 
border  of  the  velum,  and  may  fill 
the  entire  nasopharynx. 

Though  frequently  hereditary — 
i.e.,  of  familial  type,  and  occasion- 
ally congenital — it  is  believed  that 


Fig.  1'. 


-Adenoid  facies  and  chest. 


Fig.  128.— Mouth-breather. 


this  tendency  to  overgrowth  of  lymphoid  tissue  may  result  through 
transmission  of  other  debilitating  parental  dyserasia\  Adenoids  fre- 
quently accompany  cleft  palate  and  are  common  in  deaf-mutism,  which 
in  some  instances  is  regarded  as  a  result  of  these  vegetations. 

Symptoms. — Among  the  early  symptoms  of  adenoids  are  snoring  in 
sleep;  restlessness;  recurrent  attacks  of  nasopharyngeal  catarrh;  bad 
breath;    bloody   discharge   from   the   nose   or   throat,    or   tendency   to 

15 


>26 


DISORDERS    OF    THE    DIGESTIVE    SYSTEM 


epistaxis;  sensitive  throat  with  tonsillar  hypertrophy;  susceptibility  to 
taking  cold  upon  slight  exposure ;  pyrexia  from  insignificant  causes ; 
laryngeal  spasm  with  or  without  laryngitis ;  bronchial  asthma,  and  cough 
without  bronchial  lesion. 

Advanced  cases  present  appearances  so  typical  that  "adenoid  facies" 
stands  for  a  symptom  complex  of  this  condition  (Figs.  127  and  128).  The 
sallow  complexion;  thick,  expressionless  lips;  open  mouth;  crowded, 
irregular  teeth,  with  arched  or  saddle-shaped  palate;  narrow  nostrils 
with  weak  alae  showing  indentation  at  juncture  of  superior  and  anterior 
lateral  cartilages ;  the  flattened  nasal  bridge  with  its  congested  transverse 
vein :  and  the  dull  eyes  having  the  appearance  of  being  too  wide  apart, 
with  their  frequently  congested  tarsal  structures ;  also  dulness  of  hearing 
and  the  want  of  alertness,  all  give  to  the  confirmed  mouth-breather  the 
appearance  of  sluggish  or  deficient  mentality.  The  voice  is  nasal  and 
non-resonant,  especially  in  singing,  and  the  consonants  M  and  N  are 
sounded  as  B  and  D,  respectively. 

The  effects  of  obstructed  respiration  in  neglected  cases  appear  in 
general   malnutrition,   muscular    atony,    anosmia,    headaches,    disturbed 


Fig.  129.— High-arched  palate. 


sleep,  bad  dreams,  night  terrors,  nervous  instability,  with  disturbed  re- 
flexes, and  possibly  epilepsy.  The  appetite  is  impaired;  digestion  dis- 
turbed ;  deafness  with  or  without  aural  discharge  is  common ;  ocular  dis- 
turbances are  not  infrequent,  with  phlyctenular  of  the  conjunctiva?. 
Growth  is  retarded,  and  the  chest  may  show  marked  rhachitic  deformity 
with  shallow  respiration.  The  child  is  the  victim  of  every  intercurrent 
disorder,  both  dietetic  and  infectious ;  while  bronchopneumonia  and 
tuberculosis  are  ever  threatening  finalities  in  the  sequence  of  morbid 
processes. 

The  abundance  of  lymph  follicles  in  the  retronasal  and  pharyngeal 
mucosa  in  infancy  is  undoubtedly  the  predisposing  cause  of  adenoids  at 
this  period,  while  the  low,  receding  pharyngeal  vault,  with  the  meagre 


ADENOIDS 


227 


postnasal   openings,    are   largely   accountable    for   their   obstruction   to 
respiration. 

Exposure  to  cold  and  dampness,  with  resulting  rhinopharyngeal 
catarrh,  is  a  recognized  cause.  The  first  appearance  of  symptoms 
frequently  follows  an  attack  of  diphtheria,  measles,  scarlatina,  or 
influenza.  The  most  commonly  observed  age  for  troublesome  adenoids  is 
from  three  to  ten   years,   though  the  first  symptoms   usually   appear 


Fig.  130.— Digital  exploration  for  adenoids. 

between  one  and  three  years,  and  occasionally  are  seen  from  earliest 
infancy. 

Much  confusion  still  exists  as  to  the  etiologic  relationship  between 
some  of  the  prominent  accompaniments  of  adenoids  and  the  postnasal 
vegetations  themselves.  Recurrent  rhinitis  is  undoubtedly  both  a  cause 
and  an  effect  of  the  post-nasal  hypertrophy.  The  occlusion  of  the  Eu- 
stachian tubes,  which  interferes  with  the  ventilation  of  the  tympanum 
with  the  consequent  congestive,  exudative,  or  suppurative  otitis,  may 
be  due  to  hyperplastic  constriction  of  their  orifices  independent  of  any 
obstruction  by  the  masses  of  hypertrophied  Luschka's  tonsil. 


228  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

The  term  "adenoid  habit"  has  been  applied  to  a  tendency  to  hyper- 
trophic changes  in  the  lymphoid  ring  which  includes  the  postnasal 
space,  vault,  and  posterior  pharyngeal  wall,  pharyngeal  tonsil,  and 
postdorsal  surface  of  the  tongue. 

Mental  dulness  may  be  induced  by  plugging  the  inferior  nasal  pas- 
sages with  wax,  and  eye  disturbances  have  followed  suturing  the  nostrils 
in  rabbits. 

The  changes  in  the  upper  respiratory  and  lymph-tracts  of  the  mouth- 
breather — viz.,  the  narrow  face  and  high  palate,  which  diminishes  the 
capacity  of  the  nares,  causing  congestion  of  blood-  and  lymph-vessels — 
may  be  due  either  to  hereditary  or  mechanical  influences,  as  pressure, 
prenatal  or  parturient,  which  would  cause  narrowing  of  the  facial 
bones.  In  such  cases  hypertrophy  of  the  pharyngeal  lymphoid  tissue 
would  only  be  a  part  of  the  morbid  sequence.  Stagnation  of  lymph-chan- 
nels—Sehneiderian,  antral,  and  ethmoidal — follows.  Cerebral  effects, 
such  as  mental  dulness,  headaches,  accompanied  by  trophic  disturbances, 


Fig.  131.— Effect  on  jaws  of  thumb-sucking  and  continued  use  of  the  "soother"  during  infancy. 

may  be  occasionally  ascribed  to  impaired  function  of  the  pineal  and 
pituitary  bodies. 

That  the  deformity  of  face,  palate,  alveolar  arches,  nasal  septum, 
and  meati  are  caused  solely  by  the  postnasal  obstruction,  there  is  reason 
to  doubt.  A  more  natural  explanation  is  that  accorded  to  pressure,  both 
direct  and  atmospheric,  caused  by  thumb-sucking,  late  nursing  from 
breast  or  bottle,  and  the  continued  use  of  the  ' '  soother. ' ' 

Diagnosis. — Adenoids  may  be  suspected  in  infants  or  children  who 
exhibit  symptoms  of  obstructed  respiration,  recurrent  nasopharyngeal 
catarrh,  deafness  or  otitis,  general  malnutrition,  anaemia  or  reflex  ner- 
vous disturbances.  The  presence  of  these  growths  may  be  verified  by 
palpation.  The  child  must  be  held  with  arms  secured,  sitting  on  the 
lap  of  an  assistant,  while  the  physician  stands  above  so  that  his  index 
finger  may  enter  the  angle  of  the  mouth,  pass  readily  behind  the 
velum,  and  gently  explore  the  vault  with  palmar  surface  and  tip  (Fig. 
130).  A  gag  between  the  jaws  will  insure  greater  freedom  and  safety 
to  the  examiner.  The  vegetations  may  be  felt  as  soft,  velvety  masses, 
like  angleworms,  or  in  ridges,  cushions,  or  lobules,  at  the  posterior  nares 


ADENOIDS  22'.) 

or  on  the  pharyngeal  vault.  Hypertrophy  may  be  felt  with  the  trained 
finger  when  but  little  can  be  seen  with  the  rhinoscope.  Posterior  rhin- 
oscopy, with  tractable  older  children,  gives  good  results  and  is  u  valuable 
adjunct  in  diagnosis  when  tonsillar  enlargemenl  is  no1  too  great. 

Adenoids  may  be  differentiated  from  fibroids  as  much  softer,  more 
friable,  and  not  so  well  denned.  Malignant  growths  are  extremely  rare 
in  this  situation.  Polypi  of  the  nasopharynx  or  of  the  nasal  fossa?  are 
very  rare  in  infancy  and  early  childhood.  Retropharyngeal  abscess  runs 
too  acute  a  course  to  be  mistaken  for  adenoids.  Nasal  obstruction  may 
be  excluded  by  nebulizing  into  one  nostril  albolene,  or  other  oily  sub- 
stance, which  should  be  returned  through  the  other  nostril  if  the  meati 
are  patulous. 

Aside  from  their  effects  in  lowering  resistance  to  infection  through 
trophic  influence,  the  role  of  adenoids,  not  only  in  their  furnishing  in 
the  nearly  closed  cavity  of  the  pharynx  an  ideal  incubator,  but  also  in 
affording  through  their  masses  ready  entrance  to  the  circulation  of  path- 
ogenic organisms,  is  of  vast  pathologic  importance.  Rheumatic  infec- 
tion is  so  commonly  associated  with  activity  in  the  structures  composing 
the  lymphoid  ring  that  tonsillar  hypertrophy  is  accepted  as  one  of  the 
signs  of  the  rheumatic  diathesis. 

Tubercle  bacilli  in  Luschka's  tonsil,  with  characteristic  lesions,  are 
reported  by  many  observers,  ranging  in  frequency  from  three  to  ten  per 
cent,  of  the  cases  examined.  Primary  tuberculosis  of  adenoids  is  prob- 
ably more  common  than  earlier  studies  have  shown. 

Prognosis. — During  pubescence  the  amplification  of  the  pharyngeal 
vault  and  the  heightening  of  the  nasal  fossa?  relieve  somewhat  the  ob- 
structive symptoms  of  adenoids.  At  this  time,  or  earlier,  the  growths 
themselves  usually  tend  to  atrophy ;  the  overgrowth  of  fibrous  tissue,, 
which  is  perivascular  in  its  arrangement,  probably  hastens  this  result. 

The  removal  of  the  adenoids  may  relieve  obstruction  to  respiration 
and  interrupt  the  resultant  morbid  processes,  but  the  damage  to  aural 
structures  and  the  trophic  effects  of  their  prolonged  influence  may  be 
beyond  repair.  The  physician  should  be  conservative  in  his  estimate  of 
the  benefit  to  be  derived  from  treatment  or  even  removal. 

Treatment. — The  treatment,  is  prophylactic,  palliative,  and  curative. 
Anything  that  tends  to  interrupt  the  vicious  circle  of  which  adenoids 
form  a  part,  retards  by  so  much  their  growth ;  hence,  protection  from 
catarrhal  infections  by  attention  to  clothing,  climate,  and  ventilation 
must  be  observed,  with  prompt  treatment  for  the  relief  of  acute  angina 
and  rhinitis.  Nutrition  must  be  maintained  to  the  highest  degree  by 
the  best  known  hygiene,  special  attention  being  directed  towards  any 
tendency  to  rhachitis  and  other  nutritional  disorders.  In  this  connec- 
tion the  services  of  the  physician  are  rarely  more  valuable  than  during 
convalescence  from  the  contagious  diseases  of  infancy  and  childhood. 

The  question  of  early  orodental  surgery  to  correct  facial,  palatal, 
and  nasal  deformities  due  to  prenatal  or  hereditary  influences  seems 
worthy  of  consideration. 


230  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

Much,  may  be  accomplished  by  a  thorough,  daily  toilet  of  the  nose, 
pharynx,  and  mouth.  From  infancy  children  may  be  habituated  to  the 
use  of  bland  medicated  albolene  nebulizations,  also  to  sprays  of  common 
salt  or  boric  acid  in  aqueous  solution. 

When  the  adenoid  is  small,  or  appears  as  a  somewhat  acute  growth, 
medicinal  and  hygienic  treatment  may  arrest  its  development  or  even 
occasionally  cause  marked  shrinkage.  Guaiacol  carbonate,  one  to  three 
grains  (0.065-0.2  Gm.),  four  times  a  day;  syrup  of  the  iodide  of  iron, 
five  to  fifteen  minims  (0.3-1.0  C.c),  three  times  daily:  or  syrup  of 
hydriodic  acid,  fifteen  to  sixty  minims  (1.0-3.75  C.c),  three  times  daily, 
may  be  given  on  alternate  weeks  for  a  period  of  several  months. 

When  the  growth  causes  trouble  in  the  auditory,  respiratory  or  ner- 
vous systems  prompt  removal  of  the  obstruction  by  surgical  procedure 
must  be  the  rule. 

Unless  the  conditions  are  urgent  the  operation  should  be  deferred 
until  after  the  second  year.  Early  summer,  for  obvious  reasons,  is  a 
more  suitable  time  than  late  fall  or  winter.  An  acute  angina  or  rhinitis 
would  warrant  postponement  until  recovery.  Since  adenoids  furnish  a 
route  for  infections,  care  must  be  observed,  in  operating,  to  avoid  states 
where  reinfection  is  likely  to  occur,  as  after  acute  infectious  disorders, 
or  during  epidemics  where  exposure  is  possible.  Eecent  endo-  or  peri- 
carditis, rheumatism,  or  chorea,  should  warn  the  surgeon  to  wait  for 
complete  recovery. 

The  list  of  disorders  in  which  relief  has  followed  the  removal  of 
adenoids  includes  voice  defects,  mouth-breathing,  mental  dulness.  epis- 
taxis,  ha?matemesis,  headache,  deafness,  otitis  and  rhinitis,  bronchitis, 
laryngitis,  asthma,  laryngospasm,  stammering,  chorea,  rheumatic-  attacks, 
enuresis,  broken  sleep,  night  terrors,  tetany,  convulsive  seizures  from 
apparently  innocent  causes,  masturbation,  many  nervous  habits  and  tics 
of  reflex  origin,  adenitis,  torticollis,  sclerosis  and  other  orthopaedic  condi- 
tions due  to  lowered  nutrition  and  repeated  infections ;  also  indigestion, 
diarrhceal  attacks,  and  malnutrition. 

RETROPHARYNGEAL    ABSCESS. 

Retropharyngeal  abscess  is  peculiar  to  infancy.  It  is  rarely  seen 
after  the  third  year  and  occurs  oftenest  from  the  sixth  to  the  fourteenth 
month.  The  collection  of  pus  between  the  posterior  pharyngeal  wall 
and  the  vertebral  column  is  most  frequently  due  to  a  suppurative  in- 
flammation of  the  lymph  nodes  with  which  this  region  is  well  supplied 
in  infancy.  After  the  third  year  this  chain  of  glands  usually  under- 
goes atrophy.  This  form  of  retropharyngeal  abscess  has  been  termed 
primary  or  idiopathic,  although  it  is  undoubtedly  due  to  infection 
through  the  lymph  channels  from  the  faucial  or  pharyngeal  mucosa.  It 
occasionally  results  from  the  burrowing  of  pus  in  cervical  tuberculous 
spondylitis. 

A  predisposition  to  this  affection  is  seen  in  children  of  syphilitic, 
tubercular,  or  lymphatic  diathesis.    It  has  been  known  to  follow  trauma, 


RETROPHARYNGEAL    ABSCESS  231 

as  wounds  to  the  mouth  or  pharynx,  and  at  limes  it  develops  as  a  sequel 
to  the  acute  infectious  diseases  of  childhood. 

Symptoms. — Although  the  condition  is  usually  accompanied  by  fever 

and  other  evidences  of  abscess  formation,  the  first  symptom  to  attract 
attention  to  the  lesion  is  interference  with  swallowing  and  breathing. 
The  baby  refuses  to  nurse,  or  repeatedly  lets  go  of  the  nipple.  The 
mother  may  have  noticed  a  peculiar  sound  with  inspiration,  like  a  soft 
snore  or  clucking  noise,  which  may  have  been  attributed  to  nasal  obstruc- 
tion or  to  laryngeal  stenosis  from  croup.  There  may  be  labored  efforts 
at  inspiration  with  depressions  of  the  yielding  portions  of  the  chest  wall, 


Fig.  132.— Cervical  spondylitis,  retropharyngeal  abscess,  otitis  media. 

with  cyanosis  and  evidences  of  impending  asphyxia.  The  cry  has  a 
peculiar  throaty  quality  as  though  the  infant  were  being  strangled. 
The  attitude  is  characteristic  (Fig.  132),  the  head  being  inclined  back- 
wards and  towards  the  affected  side.  Lymph-nodes  may  be  felt  under 
the  angle  of  the  jaw  and  occasionally  a  tumefaction  appears  behind  the 
sternomastoid  muscle.  The  mouth  may  be  open,  as  with  nois}^  breathing 
the  child  endeavors  to  overcome  the  respiratory  obstruction.  The  facial 
expression  in  older  infants  denotes  anxiety  and  is  sometimes  indicative 
of  pain.  Inspection  of  the  mouth  may  reveal  nothing  abnormal,  or  the 
soft  palate  may  bulge  forward  and  a  fulness  of  the  posterior  pharyn- 
geal wall  is  apparent.  In  either  case  the  pharynx  should  be  carefully 
explored  with  the  finger  (Fig.  130),  when  the  presence,  the  dimensions, 
and  the  consistency  of  the  tumor  may  be  readily  made  out.    The  abscess 


232  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

may  be  high  up  behind  the  soft  palate,  or  low,  opposite  the  laryngeal 
orifice,  and  is  usually  at  one  side  of  the  median  line.  A  word  of  caution : 
the  abscess  may  be  ruptured  by  the  exploring  finger,  in  which  case  the 
baby  should  be  immediately  turned  head  downward  to  prevent  the 
escaping  pus  from  entering  the  glottis. 

In  the  suppurative  form  the  onset  is  rapid,  so  that  acute  dyspnoea 
may  develop  within  twenty-four  hours  after  the  first  symptom.  Oc- 
casionally, however,  lymphadenitis  of  the  retropharyngeal  area  may 
not  proceed  to  suppuration,  in  which  case  the  symptoms  of  pain  and 
dyspnoea  become  less  marked  and  .disappear  spontaneously. 

The  tuberculous  variety,  with  burrowing  pus,  is  gradual  in  develop- 
ment and  may  produce  symptoms  of  pharyngeal  encroachment  increas- 
ing throughout  a  period  of  several  weeks. 

Diagnosis. — To  one  familiar  with  the  picture  of  retropharyngeal  ab- 
scess the  diagnosis  is  not  difficult  and  may  always  be  made  by  explora- 
tory palpation,  when  inspection  is  unsatisfactory.  Laryngeal  stridor  and 
spasmodic  laryngitis  cause  paroxysms  of  dyspnoea,  whereas  the  respira- 
tory difficulty  in  retropharyngeal  abscess  is  continuous.  The  cough, 
too,  of  catarrhal  laryngitis,  is  loud  and  clanging,  while  that  of  abscess 
has  no  croupy  quality.  Diphtheria  of  the  larynx  gives  a  husky  cry  or 
complete  aphonia,  and  may  show  diphtheritic  membrane  on  other  por- 
tions of  the  faucial  or  nasal  mucosa.  The  position  of  the  head  in  retro- 
pharyngeal abscess  is  characteristic  and  is  seen  in  no  other  obstructive 
lesion.  If  the  abscess  be  seated  low  down,  or  if  it  be  accompanied  by 
oedema  of  the  glottis,  the  obstructive  symptoms  from  pressure  may  closely 
resemble  those  of,  laryngitis,  from  which  it  may  be  diagnosed  only  by 
palpation. 

As  young  infants  rarely  breathe  through  the  mouth,  obstructive  res- 
piration due  to  occlusion  of  the  nares  may  be  relieved  by  pressing  the 
mouth  open. 

Prognosis. — The  prognosis  is  grave  because  of  the  possibility  of  acci- 
dent. Death  may  occur  from  asphyxia,  especially  in  feeble  infants. 
Spontaneous  rupture  of  the  abscess  during  sleep  is  always  attended  by 
danger  of  suffocation.  Early  diagnosis  and  proper  treatment  is  almost 
always  followed  by  speedy  recovery. 

Treatment. — The  abscess  should  be  opened  and  its  contents  evacuated. 
A  straight  bistoury,  guarded  to  one-quarter  inch  of  its  point,  may  be 
guided  by  the  index  finger  of  the  left  hand  to  the  most  prominent  part 
of  the  tumor  and  a  vertical  incision  made  from  one-half  to  one  inch  in 
length.  The  child,  with  jaws  separated  by  a  mouth  gag,  arms  pinioned 
in  a  sheet,  and  held  by  an  assistant,  should  be  inverted  instantly  upon 
the  withdrawal  of  the  knife,  to  prevent  aspiration  of  the  pus  into  the 
larynx.  After  this  the  finger  should  be  again  introduced  and  pressure 
made  to  empty  completely  the  abscess  cavity.  The  child  should  be 
kept  under  observation  for  several  days,  as  the  incision  may  heal  too 
quickly  and  the  cavity  refill.  In  this  case  a  second  operation  will  be 
necessary.     In  many  instances,  especially  in  those  where  the  abscess  is 


DISEASES    OF    THE    (ESOPHAGUS  233 

due  to  tuberculosis  of  the  cervical  vertebrae,  operation  from  the  outside 
of  the  neck  is  preferable.  By  this  means  the  danger  of  infection  of  the 
tuberculous  tract  with  pus  germs  is  lessened  and  better  drainage  is 
secured. 

The  condition  of  the  infant  usually  calls  for  restorative  and  tome 
treatment  to  improve  nutrition  and  combat  the  depression  caused  by 
the  suppurative  process. 

Probably  the  prophylaxis  resides  in  attention  to  the  daily  toilet  of 
the  mouth  and  upper  respiratory  tract,  especially  in  infants  who  are 
predisposed  to  catarrhal  and  suppurative  lesions,  also  in  those  suffering 
from  the  acute  exanthems. 

DISEASES   OF   THE    (ESOPHAGUS. 

The  oesophagus  is  rarely  the  seat  of  pathological  processes  in  chil- 
dren. When  they  do  occur,  however,  they  are  of  so  grave  importance 
as  to  merit  mention.  As  stated  on  page  159,  congenital  defects  of  the 
oesophagus  are  occasionally  seen, — such  as  stenosis  complete  or  partial, 
diverticula,  tracheo-oesophageal  fistula,  imperfect  closure  of  a  branchial 
cleft,  or  entire  absence  of  the  oesophagus. 

Congenital  narrowing  of  the  oesophagus  near  its  lower  end  may  allow 
some  of  the  food  to  pass  into  the  stomach,  although  a  portion  is  regurgi- 
tated. The  oesophagus  gradually  becomes  dilated  or  succulated  above 
the  constriction.  The  digestion  may  be  good,  but  the  stools  are  scanty 
and  the  child  succumbs  to  inanition.  Passage  of  a  bougie  may  locate  the 
constriction  and  determine  its  extent.  The  relief  is  by  surgical  opera- 
tion after  reasonable  efforts  at  dilatation  have  failed.  Rectal  feeding 
should  supplement  that  by  the  mouth  until  an  operation  may  be  made, 
and  should  constitute  a  part  of  the  after  treatment. 

A  tracheo-oesophageal  fistula  usually  terminates  in  an  aspiration 
pneumonia. 

Acute  oesophagitis  may  be  caused  by  the  ingestion  of  corrosive  liquids, 
such  as  acids,  ammonia,  concentrated  lye,  or  even  hot  drinks ;  also  from 
the  swallowing  of  foreign  bodies  which  lacerate  the  mucous  membrane, 
or  become  impacted  and  set  up  inflammation  by  their  presence.  Diseases 
of  the  mouth  and  pharynx,  such  as  diphtheria  and  thrush,  by  extension, 
may  involve  the  entire  length  of  the  gullet,  diminishing  or  completely 
occluding  its  lumen  with  a  solid  mass  of  parasitic  growth. 

The  symptoms  of  oesophagitis  are  dysphagia  or  aphagia,  salivation, 
and  vomiting.  The  child  cries  and  refuses  to  take  food,  or  the  fluids 
may  be  regurgitated  with  evidence  of  pain.  There  are  usually  some 
febrile  symptoms. 

The  presence  of  membranous  or  mycotic  lesions  of  the  mouth  or  throat 
may  confirm  the  diagnosis  of  oesophageal  complication.  In  other  cases 
there  may  have  been  a  history  of  traumatism.  If  a  foreign  body  has 
been  swallowed  the  physician  should  satisfy  himself  that  this  has  not 
been  retained  in  the  oesophagus.  He  should  remember  the  three  nor- 
mal constrictions — namely,  pharyngeal,  diaphragmatic,  and  that  portion 


234  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

crossed  by  the  aorta, — the  narrowest  of  which  is  the  upper,  where  fiat 
bodies  are  wont  to  lodge  in  close  relation  to  the  posterior  walls  of  the 
larynx  (Fig.  134).  In  this  position  they  may  be  easily  removed  with 
the  curved  forceps.  The  fluoroscope  is  invaluable  in  locating  foreign 
bodies  that  have  been  swallowed,  so  that  much  harmful  probing,  for- 
merly thought  necessary,  may  now  be  avoided.  It  is  important  that 
lodged  bodies  be  properly  removed  from  the  oesophagus  before  swell- 
ing increases  the  impaction  and  results  in  inflammation  and  ulcera- 
tion. If  low  down,  soft  foods,  such  as  mush  or  mashed  potatoes,  should 
be  given,  or  the  probang  may  be  gently  used  to  push  it  through  the 
cardiac  orifice.  (Esophagotomy  may  be  necessary;  or  gastrotomy,  as  a 
less  difficult  operation,  may  be  performed. 

Oesophagitis  from  extension  of  oral  thrush  should  be  treated  by  the 
administration  of  alkalies,  as  bicarbonate  of  soda,  Vichy  water,  etc.  It 
may  be  necessary  to  pass  a  bougie  or  rubber  tube  through  to  the  stom- 
ach to  dislodge  the  fungoid  growth  from  the  lining  membrane.  When 
corrosive,  acids  or  alkalies  are  swallowed,  they  should  be  immediately 
followed  by  a  neutralizing  solution  and  later  by  sweet  oil  or  albolene.    In 


Fig.  134. — Extreme  emaciation  from  stricture  of  the  oesophagus.     (Dr.  J.  A.  Kohinson.) 

inflammation  of  the  oesophageal  mucosa  from  any  cause,  feeding  by  the 
mouth  is  contraindicated  and  rectal  alimentation  must  be  temporarily 
substituted  until  the  parts  have  had  time  to  heal,  although  ice  cream 
and  small  lumps  of  ice  may  be  taken  and  frequently  will  alleviate  the 
pain  and  satisfy  the  thirst.  Anodynes  are  rarely  required,  although  a 
small  dose  of  codeine  may  be  given  when  necessary  to  secure  sleep. 

Suprarenal  extract  is  worthy  of  trial  to  diminish  the  hyperemia. 

Strictures  of  the  oesophagus  invariably  follow  deep  erosions  of  its 
lining  membrane  by  the  action  of  acid,  alkalies,  scalding  fluid,  or  steam. 
Some  months  may  elapse  after  recovery  from  the  traumatism  before  the 
stricture  is  severe  enough  to  cause  symptoms  (Figs.  134, 135).  The  relief 
of  these  acquired  strictures  should  be  sought  in  surgical  measures. 

Functional  disturbances  of  the  oesophagus  are  not  rare,  such  as  reflex 
hyperexcitability  with  spasmodic  atresia.  This  is  particularly  notice- 
able in  children  of  neurotic  heredity. 

It  has  been  termed  a  local  hysteria  which  occasionally  gives  rise  to 
dysphagia  or  aphagia,  regurgitation  of  liquids  or  solids,  and  belching 
of  gas.     Undoubtedly  oesophageal  spasm  is  an  important  element  in  all 


DISEASES    OF    THE    (ESOPHAGUS 


235 


organic  and  inflammatory  lesions,  as   frequently  a   stricture  that  pre- 
vents the  passage  of  a  bougie  disappears  under  chloroform. 

The  treatment  for  this  purely  nervous  phase  of  oesophageal  disorders 


Fig.  135.— Stricture  of  oesophagus. 

is  in  the  use  of  antispasmodics:  bromide,  valerian,  or  asafetida;  and 
by  general  nerve  tonics :  iron,  quinine,  and  strychnia,  by  cold  bathing 
and  properly  directed  suggestion. 


RETRO-CESOPHAGEAL     ABSCESS. 

Retro-cesophageal  abscess  is  occasionally  found  post-mortem  in  chil- 
dren in  whom  it  was  the  immediate  cause  of  death  from  pressure  on  the 
pneumogastric  nerve.  Abscess  in  this  locality  may  be  due  to  burrow- 
ing of  pus  from  a  retropharyngeal  abscess,  or  may  be  the  result  of  Pott's 


236  DISORDERS    OF    THE    DIGESTIVE    SYSTEM 

disease  of  the  cervical  or  upper  dorsal  vertebra?  (Fig.  132),  or  of  suppu- 
rative adenitis  of  the  postoesophageal  lymph-nodes,  following  scarlet  fever, 
measles,  and  influenza.' 

The  most  prominent  symptom  of  post-  or  periesophageal  abscess 
is  dyspnoea,  most  marked  on  inspiration,  but  without  disturbance  of 
deglutition.  Diagnosis  is  rarely  made  during  life.  This  condition  may 
be  suspected  in  tuberculosis  of  the  lower  cervical  or  upper  dorsal  verte- 
bras when  dyspnoea  and  spasmodic  irritative  cough  are  present. 

The  dyspnoea  may  call  for  tracheotomy.  Spontaneous  relief  may  fol- 
low rupture  into  the  cesophagus,  or  rupture  into  the  trachea  may  cause 
death  from  suffocation.  Surgery  should  be  invoked  for  the  possible 
relief  by  drainage  through  external  incision. 


CHAPTER    VI 
DISEASES   OF   THE   GASTRO-ENTERIC    TRACT 

VOMITING 

Vomiting,  although  properly  regarded  as  a  symptom,  occurs  in  so 
many  widely  diverse  disorders  that  brief  mention  of  a  few  of  the  more 
common  is  appropriate. 

Perfectly  healthy  infants  frequently  vomit  immediately  after  nurs- 
ing, the  returned  milk  showing  little  or  no  change  in  odor  or  consistency. 
In  this  case  the  act  is  merely  one  of  regurgitation  due  to  repletion  and 
is  probably  conservative.  It  is  unaccompanied  by  nausea,  pain,  or  any 
change  in  the  attitude  or  temper  of  the  infant.  It  is  significant  only  of 
hasty  or  overfeeding  and  is  invariably  corrected  (excepting  in  occasional 
cases  where  it  has  become  a  habit)  by  attention  to  the  hygiene  of  feed- 
ing (q.v.).  A  word  of  caution  may  be  necessary  in  regard  to  passing 
over,  as  unimportant,  all  cases  of  regurgitation,  since  obstinate  dyspepsia 
may  frequently  have  its  beginning  in  overfeeding. 

Vomiting  of  Indigestion. — Vomiting  is  the  most  common  symptom  of 
acute  dyspepsia  and  is  usually  accompanied  by  epigastric  pain  or  dis- 
comfort and  nausea,  symptoms  of  the"  latter  frequently  appearing  in 
pallor  of  the  prolabia  and  facial  grimacing.  Elevation  of  temperature 
commonly  accompanies  this  form,  also  prostration  of  varying  degree,  de- 
pendent upon  the  nature  and  continuation  of  the  cause.  That  irritation 
of  the  stomach  from  the  products  of  indigestion  is  the  cause  of  the 
emesis  is  confirmed  by  the  character  of  the  vomitus.  which  is  abnormally 
acid  and  may  show  putrefactive  changes.  In  milk-fed  babies  the  con- 
tents of  the  stomach  may  be  ejected  in  dense,  cylindrical,  sour-smelling 
curds,  so  large  that  strangulation  seems  imminent  and,  indeed,  is  an 
occasional  occurrence.  To  this  class  belongs  emesis  from  any  agent  that 
causes  direct  irritation  of  the  gastric  mucosa,  whether  chemical  or 
mechanical. 

Vomiting  is  a  prominent  symptom  of  obstructive  lesions  of  the 
prima  via,  whether  oesophageal,  pyloric,  or  intestinal,  as  in  intussuscep- 
tion, volvulus,  or  fecal  impaction.  An  attack  of  appendicitis  also  is 
usually  accompanied  by  vomiting.  As  these  subjects  are  all  discussed 
elsewhere,  it  may  suffice  here  to  refer  merely  to  the  stercoraceous  char- 
acter of  the  vomitus  in  persistent  lower  bowel  obstruction,  and  to  the 
intermittent  profuse  emesis  from  the  greatly  dilated  stomach  of  pyloric 
stenosis. 

In  infants  and  young  children,  pyrexia,  independent  of  its  cause,  is 
rarely  unattended  by  vomiting.  This  is  not  so  true  of  older  children 
where  a  sudden  rise  of  temperature,  preceded  or  accompanied  by  vomit- 

237 


238        DISEASES    OF    THE    GASTROENTERIC    TRACT 

ing,  is  very  suggestive  of  the  onset  of  an  acute  exanthem.  This  is 
particularly  true  of  scarlet  fever,  erysipelas,  and  variola.  A  charac- 
teristic of  the  initial  vomiting  in  eruptive  fevers  is  that  it  is  very  rarely 
repeated. 

Under  the  head  of  reflex  vomiting  is  included  the  occurrence  of 
emesis  from  causes  independent  of  the  stomach  and  its  contents.  Good 
illustrations  of  this  type  are  seen  in  the  cerebral  vomiting  in  meningitis, 
cerebral  tumor,  or  in  cerebellar  disease.  In  this  class  the  vomiting  is 
projectile  in  character  and  occurs  without  nausea,  coated  tongue,  or  other 
evidences  of  indigestion.  Reflex  vomiting  may  be  caused  by  pain  or 
irritation  in  parts  remote  from  the  stomach,  as  in  otalgia,  dentition,  eye- 
strain and  intestinal  worms. 

Irritation  of  the  fauces  undoubtedly  belongs  to  the  reflex  class  of 
causes,  and  may  explain  the  vomiting  due  to  pertussis,  paroxysms  of 
coughing,  or  to  expectoration  of  tenacious  mucus.  The  presence  of 
adenoid  growths  in  the  nasopharynx  may  cause  vomiting  by  reflex  excita- 
tion. The  effects  of  shock  from  blows,  falls,  or  burns  in  the  production 
of  emesis  are  explained  in  this  way.  Neurotic  vomiting,  aside  from 
that  which  occurs  in  nervous  dyspepsia,  may  be  occasioned  by  fright, 
outbursts  of  anger,  excitement,  fatigue,  or  grief,  in  susceptible  children, 
and  especially  in  nervous  girls  of  the  chlorotic  type. 

Toxaemia  from  any  cause  may  be  accompanied  by  vomiting  which,  if 
persistent,  should  lead  to  an  examination  of  the  urine  for  possible 
nephritic  disorder. 

Allied  to  the  toxaemic  is  the  disorder  known  as  recurrent  or  cyclic 
vomiting.  This  may  develop  at  any  age,  but  is  most  frequently  seen 
between  the  second  and  seventh  years.  A  peculiarity  of  this  disorder  is 
its  cyclic  character,  the  attacks  recurring  at  intervals  of  from  a  few 
weeks  to  several  months.  During  the  intervals,  the  child  enjoys  his 
normal  health.  The  vomiting  may  be  ushered  in  by  prodromes,  such  as 
anorexia,  malaise,  coated  tongue,  sweetish  odor  of  breath,  constipation, 
elevation  of  temperature,  and  hebetude.  In  a  child  subject  to  this  dis- 
order, any  of  the  above  symptoms  give  warning  of  an  approaching 
paroxysm.  The  first  emesis  may  eject  only  the  partially  digested  con- 
tents of  the  stomach  and  resemble  an  attack  of  acute  dyspepsia. 
The  nausea  and  vomiting  continue  until  glairy  mucus,  tinged  with  bile 
or  slightly  blood-stained,  appears.  Everything  introduced  into  the  stom- 
ach, even  the  blandest  fluid,  is  promptly  ejected  and  the  usual  gastric 
sedatives  prove  futile.  In  severe  attacks  great  exhaustion  ensues  and 
even  life  may  be  threatened.  A  few  fatal  cases  have  been  reported. 
During  the  attack  the  urine  is  diminished  in  quantity,  is  highly  acid, 
and  shows  increased  percentage  of  solids.  The  urea  is  disproportion- 
ally  in  excess  of  uric  acid.  Albumin  is  occasionally  found.  The  pres- 
ence of  acetone  and  an  excess  of  the  xanthin  bodies,  both  during  and 
after  the  attack,  have  been  reported.  After  a  period  varying  in  dura- 
tion from  three  to  seven  days,  the  vomiting  suddenly  stops,  the  stomach 
resumes  its  function,  and  the  child  rapidly  regains  its  normal  status. 


VOMITING  239 

These  attacks  continue  at  intervals  of  a  few  months  until  the  approach 
of  puberty,  at  which  time,  or  before,  they  gradually  assume  the  character 
of  migraine,  which  may  terminate  in  epilepsy. 

The  etiology  of  recurrent  vomiting,  although  still  obscure,  has  been 
the  subject  of  considerable  study  in  this  country,  from  which  the  ma- 
jority of  cases  have  been  reported.  That  they  are  not  due  to  gastritis  is 
evident  from  the  sudden,  spontaneous  recovery  and  absence  of  all  gastric 
disturbance  during  the  interval.  The  theory  of  a  recurrent  neurosis  of 
the  pneumogastric  as  a  cause  of  cyclic  vomiting  seems  to  lack  proof. 
At  present  the  general  trend  of  opinion  points  to  a  lithaemic  diathesis 
as  the  underlying  cause.  A  distinct  heredity  is  seen  in  its  occurrence 
in  children  of  gouty  parentage.  A  review  of  reported  cases  shows  that 
the  attacks  occur  with  the  greatest  frequency  in  the  winter  months,  when 
elimination  by  the  skin  is  at  its  lowest. 

Treatment. — In  a  child  subject  to  cyclic  vomiting,  prophylaxis  is 
available  if  the  prodromal  symptoms  of  the  attack  be  recognized  early. 
Prompt  administration  of  full  doses  of  calomel  and  soda,  with  a  small 
quantity  of  ipecac,  at  this  stage  may  abort  the  paroxysm  or  greatly 
mitigate  its  severity.  During  the  height  of  the  seizure  free  administra- 
tion of  alkalies  is  indicated  to  counteract  the  acid  intoxication.  The  in- 
tolerance of  the  stomach  compels  resort  to  enteroclysis,  by  which  means 
from  one  to  two  drachms  of  sodium  bicarbonate  should  be  given  daily 
in  proper  solution.  Eectal  alimentation  of  predigested  food  will  be 
necessary  to  maintain  the  strength  of  the  child.  The  stomach,  mean- 
while, should  be  allowed  absolute  rest  from  food,  medicine  or  even  water. 
In  prolonged  attacks,  with  great  prostration,  a  hypodermic  injection  of 
morphine  will  control  the  vomiting,  and  the  hypodermoclysis  of  normal 
salt  solution  is  valuable  as  a  cardiac  supporter. 

Keeping  in  mind  the  litha?mic  diathesis,  the  habitual  constipation,  the 
capricious  and  frequently  voracious  appetites  of  these  children,  with 
their  proverbial  precocity  and  preference  for  mental  rather  than  physi- 
cal exercise,  the  physician  should  insist  upon  strict  adherence  to  hygienic 
and  dietetic  rules.  The  child  should  be  compelled  to  live  out  of 
doors,  even  though  withdrawal  from  school  and  study  or  an  entire 
change  of  climate  may  be  necessary.  Regular,  moderate  feeding  must 
be  enforced. 

The  diet  should  be  of  substantial  but  easily  digested  food,  of  which 
meat  proteids  should  form  but  a  small  proportion.  Questionable  fruits 
and  vegetables,  such  as  strawberries,  tomatoes,  asparagus,  rhubarb,  and 
salads,  should  be  interdicted.  Other  fruits  may  be  supplied  raw,  in 
small  quantities,  or  freely  when  cooked,  as  well  as  cereals,  milk,  eggs, 
fish,  butter,  and  occasionally  chicken,  beef,  and  mutton  in  moderate 
allowances.  Pastry,  highly  seasoned  foods,  tea,  coffee,  and  alcoholics 
should  never  be  allowed.  Free  drinking  of  water  must  be  insisted 
upon,  preferably  alkaline  and  saline,  such  as  Vichy,  Carlsbad,  Fried- 
richshall,  and  Hunyadi,  both  for  their  alkaline  and  laxative  properties. 
The  administration  at  intervals  of  an  alkali,  as  sodium  bicarbonate  or 


240         DISEASES    OF    THE    GASTRO-ENTERIC    TRACT 

benzoate,  in  moderate  doses,  three  or  four  times  daily  for  a  period  of 
two  or  three  weeks,  is  advised,  with  occasional  mercurial  or  rhubarb 
purgation. 

CONGENITAL    HYPERTROPHIC    STENOSIS    OP    THE    PYLORUS;     PYLORIC    SPASM. 

This  condition  is  reported  with  such  increasing  frequency  in  recent 
years  that  it  must  be  accepted  as  of  no  great  rarity.  Both  from  the 
symptoms  and  the  post-mortem  findings,  it  is  evident  that  the  degree 
of  stenosis  varies  in  different  cases  and  at  different  periods  in  the  same 
patient,  with  a  tendency  to  progressive  increase  in  the  narrowing  of  the 
pylorus.  It  is  also  evident  that  at  least  two  classes  of  pyloric  obstruc- 
tion are  found,— congenital  hypertrophic  stenosis,  and  spasmodic  pyloric 
constriction. 

Whatever  be  the  early  condition,  the  general  symptoms  of  pyloric 
obstruction  are  the  same,  with  the  exception  of  variations  as  to  the  time 
of  their  first  appearance.  These  are  vomiting  immediately  after  nursing 
(at  first  of  unchanged  milk  with  no  evidence  of  bile),  constipation,  or 
very  small  bowel  movements,  scanty  urine,  dilatation  of  the  stomach, 
small,  hard,  movable  tumor  in  the  pyloric  region,  visible  gastric  peri- 
stalsis, flattened  lowered  abdomen,  and  progressive  emaciation  and 
atrophy. 

Vomiting  is  the  earliest  symptom  noted  and  may  begin  within  the 
first  three  or  four  days,  or  the  infant,  apparently  well  nourished,  may 
pass  several  weeks  with  no  evidence  of  gastric  disturbance.  Usually  the 
child  is  first  treated  for  ordinary  gastric  dyspepsia.  The  stools  may 
have  been  normal  in  color  and  consistency,  so  that  constipation  and 
emptiness  of  the  bowel  with  the  persistent  vomiting  may  lead  to  the 
diagnosis  of  acute  intestinal  obstruction.  The  copious  vomiting,  the 
absence  of  bile  and  fecal  odor  and  the  dilatation  of  the  stomach  with  its 
exaggerated  peristalsis,  the  waves  of  which  may  be  seen  through  the 
attenuated  abdominal  walls,  point  to  a  lesion  of  the  pylorus.  Usually, 
this  may  be  felt  in  advanced  cases  as  a  hard  tumor,  although  in  the  early 
stage  it  may  be  concealed  by  the  overlying  liver. 

The  prognosis,  is  always  grave,  and  in  the  absence  of  intelligent  treat- 
ment positively  bad.  Lavage  and  rectal  alimentation,  withholding  all 
food  from  the  stomach  for  a  time,  administration  of  sedatives,  such  as 
bromides,  chloral,  and  belladonna,  to  overcome  spasm  of  the  pylorus,  and 
massage  with  nutrient  inunctions,  comprise  the  general  plan  of  medical 
treatment. 

After  a  time,  varying  according  to  the  case,  small  quantities  of 
bland  liquids,  such  as  albumin  water,  may  be  tentatively  administered 
by  mouth  to  test  the  stomach  as  to  the  patency  of  the  pylorus.  The 
appearance  of  yellow  stools  after  the  ingestion  of  a  little  modified  milk 
or  whey  would  encourage  perseverance  in  this  line  of  management.  Re- 
turn of  the  vomiting  with  increase  in  gastric  dilatation  should  lead  to 
surgical  interference  in  the  form  of  gastroenterostomy  or  divulsion  of 
the  pyloric  orifice. 


ACUTE    GASTRITIS  241 


ACUTE    GASTRITIS — ACUTE    GASTRIC    CATARRH  ;     ACUTE    GASTRIC    ADENITIS. 

Acute  inflammation  of  the  stomach  is  probably  not  nearly  so  common 
as  was  formerly  supposed.  Many  cases  diagnosed  as  acute  gastritis 
show  no  lesion  of  the  stomach  at  the  post-mortem. 

The  etiology  of  disorders  of  the  complex  structures  of  the  gastric 
mucosa  with  their  widely  varying  functions  must  necessarily  be  com- 
plicated and  obscure.  Among  the  apparent  causes  may  be  mentioned, 
first,  perverted  action  of  the  various  secreting  glands  with  immediate 
and  remote  results  leading  to  inflammation ;  second,  active  congestion 
from  irritation  of  the  glands,  resulting  in  gastric  adenitis ;  third,  pas- 
sive congestion  of  the  gastric  mucosa  from  interference  with  return  of 
blood  supply  through  the  liver,  resulting  in  excessive  activity  of  the 
mucous  cells.  To  these  may  be  added  traumatism  from  introduction  into 
the  stomach  of  corrosive  substances,  laceration  from  rupture  of  distended 
vessels  and  embolism  with  ulceration.  The  action  of  pathogenic  micro- 
organisms under  these  favorable  conditions  undoubtedly  plays  an  im- 
portant role  in  gastric  inflammation,  although  to  what  extent  it  is  diffi- 
cult to  say.  Acute  indigestion,  improper  food,  rapid  or  overfeeding,  the 
effects  of  cold  or  shock,  also  various  infections,  are  all  recognized  as 
exciting  causes  of  acute  gastritis. 

The  most  common  form  of  gastritis  in  early  childhood  and  infancy 
is  called  catarrhal,  although  the  more  serious  phase  of  the  disorder  lies 
in  the  adenitis  of  the  secreting  glands,  which  may  be  primary  or  sec- 
ondary to  the  catarrhal  lesions.  Macrbscopically,  the  gastric  mucosa  is 
reddened  and  swollen  in  somewhat  circumscribed  areas,  and  bathed  with 
mucus  which  may  be  stained  brown  from  slight  hemorrhage,  and  col- 
lects, by  gravitation,  towards  the  pyloric  end.  If  an  irritant  has  been 
swallowed,  erosions  of  the  mucosa  are  found  upon  the  rugae.  Pearly  or 
grayish-green  membrane  is  seen  covering  the  rugOB  along  the  greater 
curvature,  beneath  which  the  wall  of  the  stomach  is  greatly  thickened. 
This  rare  form  of  pseudomembranous  gastritis  is  seldom  diagnosed  except 
at  the  autopsy. 

Numerous  shallow  ulcerations  are  sometimes  seen,  with  pus  and  bac- 
teria, although  in  infancy  they  are  probably  of  rare  occurrence  and  never 
lead  to  perforation.  Microscopically,  patches  of  the  mucosa  are  seen 
to  be  infiltrated  with  round  cells,  and  erosions  of  the  epithelium  are 
numerous.  In  the  tubes  differentiation  between  the  principal  and  parie- 
tal cells  is  difficult.  Numerous  minute  extravasations  of  blood  are 
found,  and  the  submucous  structures  may  show  round-cell  infiltration. 

Symptoms. — The  onset  of  acute  gastritis  is  usually  sudden,  attended 
by  a  sharp  rise  in  temperature,  headache,  coated  tongue,  and  foul  breath. 
The  pulse  is  rapid,  irregular,  and  respirations  are  accelerated.  Consti- 
pation usually  precedes  the  attack,  but  may  give  way  to  diarrhcea.  The 
most  pronounced  symptom  is  vomiting,  at  first  of  sour-smelling,  partly- 
digested  food ;  later,  of  mucus  which  may  be  brown  or  black  from  slight 
hemorrhage,  or  bilious  if  the  vomiting  be  prolonged.     There  is  usually 

16  " 


242         DISEASES    OF    THE    GASTROENTERIC    TRACT 

distention  of  the  abdomen,  with  pain  and  tenderness  over  the  epigas- 
trium. In  severe  eases,  the  temperature  may  at  first  range  high,  104° 
to  105°  P.  (40°-40.5°  C.J,  occasionally  with  delirium  or,  in  young  chil- 
dren, convulsions.  Usually  after  the  first  day  the  pyrexia  is  less 
marked.  AVith  persistent  vomiting  the  coating  of  the  tongue  disappears 
from  the  tip  and  edges,  leaving  them  bright  red  in  color.  Diarrhcea  niay 
develop  early,  especially  in  infants,  and  the  persistence  of  frequent  foul- 
smelling  stools,  of  varying  color  and  consistency,  would  indicate  ex- 
tension of  the  inflammation  to  the  duodenum  and  small  intestine.  Oc- 
casionally jaundice  appears  later  as  a  result  of  the  duodenitis.  Thirst  is 
pronounced  and  insatiable  throughout  the  attack,  although  vomiting  may 
follow  every  ingestion  of  liquids.  In  infants  the  thirst  simulates  hun- 
ger, but  in  older  children  there  is  always  anorexia.  The  prostration  is 
marked,  amounting,  in  severe  cases,  to  extreme  debility  with  rapid  emaci- 
ation.   The  urine  is  scanty,  high-colored  and  heavy. 

The  attack  may  last  from  five  to  ten  days,  although,  if  mismanaged, 
it  may  continue  for  three  or  four  weeks. 

The  prognosis  is  good,  as  children  rarely  die  of  uncomplicated  gas- 
tritis. 

Diagnosis. — From  acute  indigestion,  gastritis  may  be  diagnosed  only 
by  the  persistence  of  its  symptoms,  which,  if  lasting  more  than  three  days, 
may  be  regarded  as  indicative  of  actual  inflammatory  lesions  of  the  stom- 
ach. The  diagnosis  from  the  acute  exanthems  will  be  made  by  the  appear- 
ance of  the  characteristic  rash  and  early  cessation  of  vomiting  in  the 
latter.  Pneumonia  may  be  differentiated  by  the  persistence  of  epigastric 
pain,  tenderness,  distention,  vomiting,  and  the  absence  of  other  symptoms 
and  physical  signs  of  that  disease.  From  typhoid  fever,  which  in  infancy 
and  young  children  may  closely  resemble  a  mild  gastritis  in  its  onset,  the 
differentiation  is  at  times  quite  difficult.  Epistaxis.  splenic  and  hepatic 
enlargement,  and  the  appearance  of  rose  spots  render  probable  the  diag- 
nosis of  typhoid,  which  is  confirmed  by  the  Widal  test. 

Treatment. — In  the  treatment  of  acute  gastritis,  the  withholding  of 
food  and  drink  from  the  stomach  is  of  the  first  importance.  In  infants 
and  tractable  older  children  the  stomach  should  be  washed  out  with 
sterilized  water  containing  thirty  grains  to  the  quart  (2  Gm.  to  the  litre) 
of  bicarbonate  of  soda.  Xo  treatment  for  the  pyrexia  is  required  save 
sponging  at  a  temperature  agreeable  to  the  patient.  In  older  children  an 
ice-bag  over  the  epigastrium  may  lessen  pain  and  diminish  the  frequency 
of  the  vomiting.  If  constipated,  the  bowels  should  be  immediately  re- 
lieved by  an  enema  of  soapy  water.  If  an  early  full  dose  of  castor  oil 
can  be  given  and  retained  it  will  be  of  incalculable  benefit  m  clearing 
out  the  digestive  tract,  thus  limiting  the  extension  of  the  morbid  process. 
If  the  oil  cannot  be  retained  frequent  small  doses  of  calomel,  ipecac  and 
soda  (Formula  24)  may  be  given  every  half  hour.  This  may  be  continued 
for  ten  or  twelve  doses,  when  the  interval  may  be  increased  to  two  hours. 
If  the  vomiting  be  severe  and  persistent,  bismuth  subnitrate,  two  to 
ten  grains    (0.13-0.65  Gm.),  may  be   added  to  the  dose,  with  repeti- 


GASTRIC    ULCER  243 

tion  of  the  lavage  daily.  The  thirsl  must  be  satisfied  by  small  high 
enteroelysis  of  normal  salt  solution,  three  or  four  limes  in  Ihe  twenty- 
four  hours.  Sniiill  hits  of  Lee  may  be  swallowed.  In  severe  cases  no 
attention  to  food  is  necessary  in  the  first  forty-eight  hours.  al'ler  which, 
until  subsidence  of  the  vomiting,  nourishment  musl  be  secured  by  rectal 
alimentation,  using  predigested  food  in  small  quantities.  If  prostra- 
tion be  severe  and  symptoms  grave,  stimulation  may  be  secured  by  small 
doses  of  brandy  or  aromatic  spirits  of  ammonia,  diluted  with  ice  water. 
Iced  champagne  or  the  hypodermic  use  of  strychnia  may  be  required  in 
extreme  cases.  As  the  gastric  symptoms  subside,  tincture  of  mix  vomica 
in  small  doses,  according  to  age,  properly  diluted,  may  be  given  for  its 
stomachic  effect,  three  or  four  times  a  day.  Bland  liquid  foods,  such  as 
barley-water,  albumin-water,  whey,  strained  gruels,  etc.,  should  be  cau- 
tiously administered  in  small  quantities  every  two  to  four  hours.  This 
must  be  withdrawn,  however,  on  the  reappearance  of  vomiting.  The 
return  to  the  usual  diet  should  be  gradual,  as  errors  in  this  respect  are 
largely  responsible  for  the  continuation  of  this  disorder. 

In  gastritis  from  corrosive  poisons  the  stomach  should  be  immediately 
irrigated  with  large  quantities  of  water  containing  the  chemical  antidote. 
The  child  should  be  fed  on  egg-water  until  bland  food  may  be  tolerated. 
Stimulants  should  be  administered  by  rectum  or  hypodermically. 

GASTRIC  ULCER  AND  HEMORRHAGE. 

Ulceration  of  the  stomach,  although  rare  before  puberty,  may  occur 
at  any  age  and  has  been  found  post-mortem  in  the  earliest  infancy. 

The  lesion  may  be  a  round  perforating  ulcer  presumably  of  embolic 
origin ;  multiple  follicular  ulcerations  which  are  shallow  and  usually 
seen  in  connection  with  suppurative  gastritis ;  tuberculous  ulcers  and 
ulceration  in  hemorrhagic  diseases  of  the  new-born,  or  congenital  ulcer 
of  the  stomach.  In  all  cases  the  lesion  is  probably  dependent  upon  local 
devitalized  conditions  or  dyscrasia,  such  as  purpura,  haemophilia,  leukae- 
mia, scorbutus,  septicaemia,  and  anaemia  following  the  acute  infectious 
fevers.     The  gastric  ulcer  of  the  chlorotic  girl  is  not  rare. 

The  symptoms  are  frequently  obscure,  the  ulceration  being  diagnosed 
at  the  autopsy.  There  may  be  pain  and  tenderness  and  the  usual  symp- 
toms of  acute  gastritis,  but  the  most  important  diagnostic  signs  are  blood 
in  the  vomitus  and  dark,  tarry  stools.  If  the  hemorrhage  be  consid- 
erable, evidences  of  rapidly  developing  anaemia  may  lead  to  the  sus- 
picion of  gastric  ulcer.  In  fact,  this  may  be  the  first  intimation  of  the 
lesion. 

The  prognosis  is  always  grave,  especially  in  depraved  conditions  of 
the  blood,  although  shallow  follicular  ulcerations,  when  diagnosed,  are 
amenable  to  treatment.  There  is  always  immediate  danger  of  fatal 
hemorrhage.  Ulcer  in  the  lower  end  of  the  stomach  may  upon  healing 
lead  to  cicatrization  and  pyloric  thickening  with  subsequent  stenosis. 

As  the  most  important  symptom  is  hemorrhage,  gastric  ulcer  must 
be  diagnosed  from  tuematemesis  due  to  other  causes.    Hemorrhages  of  the 


244        DISEASES    OF    THE    GASTROENTERIC    TRACT 

new-born  are  discussed  on  page  178.  Severe  and  often  fatal  hemorrhages 
may  occur  from  capillary  oozing  from  the  gastric  mucosa  in  scorbutus, 
purpura,  hemophilia,  malaria,  and  in  angemia,  or  from  passive  conges- 
tion due  to  obstructive  lesions  of  the  liver,  heart,  or  lungs.  Spurious 
haematemesis  is  very  common,  due  to  blood  previously  swallowed  from 
lesions  of  the  lips,  gums,  mouth,  throat,  adenoids  in  nasopharynx, 
and  from  fissures  of  the  nipple.  The  absence  of  gastric  symptoms 
and  the  good  condition  of  the  child  will  help  in  locating  the  source  of 
the  bleeding. 

The  treatment  for  ulcer  of  the  stomach  requires  absolute  rest  for  that 
organ,  hence  rectal  alimentation.  The  child  must  be  kept  absolutely  quiet 
by  opium  if  necessary.  Small  pieces  of  ice  may  be  swallowed.  Bismuth 
subnitrate  or  bismuth  subgallate  may  be  given  in  full  doses  and  later 
nitrate  of  silver.  Stimulants  may  be  necessary  if  there  is  much  depres- 
sion and  should  be  given  by  rectum  or  hypodermically.  The  bowels 
should  be  relieved  by  high  enemata  and  the  ice-bag  over  the  epigastrium 
may  diminish  congestion.  Reliable  preparations  of  the  suprarenal  glands 
in  appropriate  doses  should  be  administered  in  all  cases  of  severe  gastric 
hemorrhage  from  whatever  cause. 

INTESTINAL    COLIC — ENTERALGIA  ;     NEURALGIA   ENTERICA. 

Colic  in  infants  usually  means  abdominal  pain,  paroxysmal  in  char- 
acter, without  inflammatory  or  other  changes  in  the  intestines.  The 
colic  most  frequently  seen  in  young  infants  is  due  to  irregular  contrac- 
tions of  some  portions  of  the  bowel,  resulting  in  undue  pressure  from 
retained  gaseous  or  liquid  contents.  Pain  may  also  be  due  to  uric  acid 
crystals  and  concretions  in  the  renal  tubules,  pelves,  or  ureters,  and 
also  to  vesical  spasm.  Inflammatory  lesions  of  the  peritoneum,  appen- 
dix, or  any  portion  of  the  digestive  tract,  may  be  the  cause  of  pain. 
Enteralgia  may  occur  also  as  a  neurosis  with  no  apparent  local  lesion. 
So,  too,  the  pain  due  to  thoracic  inflammations,  as  pneumonia  or  pleurisy, 
may  be  referred  to  the  abdomen  in  young  children  through  involvement 
of  the  intercostal  nerves.  All  visceral  or  abdominal  inflammatory  lesions 
may  give  rise  to  pain,  more  or  less  spasmodic  in  character.  The  most 
common  cause  of  suffering  in  early  infancy  is  attributable  to  flatulent 
distention  of  the  bowel  from  the  fermentation  of  food  and  intestinal 
secretions.  Colic  occurs  in  both  breast-  and  bottle-fed  babies,  and  is 
seen  most  frequently  during  the  early  months,  in  both  well-nourished 
and  marasmic  infants,  although  with  greater  frequency  in  the  latter. 

Intestinal  colic  is  presumably  due  to  some  error  in  diet,  either  as  to 
quantity  or  quality  of  food  or  as  to  the  methods  or  frequency  of  feed- 
ing, although  an  inherent  tendency  must  occasionally  share  the  responsi- 
bility, since  twins,  nourished  from  the  same  breast,  often  show  a  remark- 
able difference  in  this  respect.  That  disturbance  in  the  normal  relation- 
ship of  the  constituents  of  breast  milk  may  affect  the  nursling  is  a  fact 
commonly  recognized,  so  that  anything  which  markedly  disturbs  the 
mother  is  likely  to  produce  colic  in  the  child    (Chapter  IV,  Part  I). 


INTESTINAL    COLIC  245 

Excess  of  proteids  appears  frequently  as  the  offending  constituent.  This 
is  more  often  seen  in  babies  fed  on  cow's  milk.  Excess  of  carbohydrates 
or  amylaceous  food  may  induce  colic  from  fermentation  of  these  sub- 
stances; also  exposure  to  cold  and  too  hasty  nursing  after  an  unusually 
prolonged  interval.  In  some  instances,  however,  no  cause;  can  be  traced 
and  the  periodicity  of  colic  under  apparently  normal  conditions,  and 
the  fact  of  its  regular  recurrence  in  the  early  evening,  still  continues 
to  furnish  an  unsolved  nursery  problem. 

The  evidences  of  colic  are  unmistakable,  although  the  determination 
of  the  cause  may  tax  the  diagnostician.  Paroxysmal  screaming,  rigid, 
distended  abdomen,  thighs  flexed  or  alternately  flexed  and  extended, 
vigorous  writhing  motions  of  the  body,  and  cold  hands  and  feet,  indicate 
abdominal  pain.  If  borborygmi  are  heard,  or  flatus  escapes  from  the 
bowel  with  evident  relief,  the  disturbance  is  surely  due  to  intestinal  colic. 
In  a  screaming  child,  with  no  evidence  of  flatus  or  spasmodic  contraction 
of  the  bowel,  the  physician  should  search  long  and  well  before  making 
a  diagnosis  of  intestinal  colic.  A  peculiarity  of  colic  as  a  transient 
functional  disturbance  appears  in  the  entire  absence  of  ill  effects  after 
the  paroxysm  has  subsided. 

Treatment. — In  the  treatment  of  intestinal  colic  no  effort  should  be 
spared  to  determine,  if  possible,  the  cause.  Examination  of  the  mother's 
milk,  observation  as  to  the  methods  of  feeding,  careful  analysis  of  all 
the  conditions  preceding  and  attending  the  attack,  and  a  study  of  the 
diapers,  may  lead  to  a  solution  and  suggest  the  means  of  correction.  For 
the  relief  of  the  paroxysm,  heat  applied  to  the  extremities  and  over  the 
abdomen,  by  means  of  hot-water  bottles  or  Japanese  hand-stoves,  massage 
of  the  abdomen  with  the  warm  hand  dipped  in  oil,  or  the  administration 
of  hot  carminative  drinks  to  relieve  the  local  spasm  and  promote  the 
expulsion  of  flatus,  are  among  the  measures  most  frequently  successful. 
A  hot  colonic  flushing  with  a  few  ounces  of  soapy  water,  to  which  a 
teaspoonful  of  milk  of  asafetida  has  been  added,  may  start  the  flatus. 
Frequent  administrations,  in  teaspoonful  doses,  of  water  as  hot  as  can  be 
borne  by  the  mouth,  to  which  a  little  kiimmel,  gin,  peppermint,  or  anise 
has  been  added,  may  cause  the  expulsion  of  gas  and  secure  relief.  Bicar- 
bonate of  soda,  in  one  or  two  grain  (0.065-0.13  Gm.)  doses,  may  be  given 
with  the  carminative.  In  obstinate  cases,  a  teaspoonful  of  castor  oil  or 
milk  of  magnesia  as  a  laxative,  followed  by  the  carminative,  may  be 
necessary.  Two  or  three  drops  of  aromatic  spirits  of  ammonia  or  one  of 
Hoffman's  anodyne  may  be  given  in  hot  water,  with  the  magnesia.  Only 
in  extreme  cases  should  an  opiate  be  resorted  to.  The  best  form  for 
this  purpose  is  paregoric,  one  to  five  minims  (0.06-0.3  Gm.)  in  hot 
water. 

Intestinal  colic  is  rarely  of  grave  import,  although  convulsions  have 
been  known  to  follow  a  prolonged  attack,  and  in  many  instances  the  colic 
is  an  early  expression  of  dyspepsia,  which  may  result  in  severe  gastro- 
enteritis. Usually,  however,  the  attacks  are  amenable  to  treatment  and 
generally  cease  after  the  third  or  fourth  month. 


216         DISEASES    OF    THE    GASTROENTERIC    TRACT 


■ACUTE  DYSPEPSIA — ACUTE  INDIGESTION. 

Dyspepsia  is  not  only  the  most  common  disorder  of  infancy  but  is 
more  largely  responsible  for  the  mortality  of  the  developing  period  than 
all  other  disorders  combined.  This  is  particularly  true  of  the  early 
period  when  the  double  burden  of  function  and  growth  taxes  the  digestive 
processes  to  their  utmost  limit.  The  most  frequent  causes  of  indigestion 
are  improper  food  or  faulty  methods  of  feeding. 

The  infant  at  the  breast  may  suffer  from  changes  that  affect  the  mam- 
mary secretion,  such  as  improper  diet,  impaired  health,  overwork,  emo- 
tional disturbances,  menstruation,  and  pregnancy.  Irregular  or  over- 
feeding is  a  frequent  cause  of  indigestion,  as  is  too  rapid  nursing  from  a 
breast  that  yields  milk  freely. 

The  child's  digestive  function  may  be  impaired  by  exposure  to  ex- 
tremes of  temperature,  by  shock,  excitement,  fatigue,  or  anything  which 
lowers  vitality  or  profoundly  affects  the  nervous  system, — as  the  intoxica- 
tion of  the  acute  infectious  diseases.  Dyspepsia  appears  in  occasional 
instances  to  be  hereditary,  as  some  infants  show  a  tendency  to  digestive 
disturbance  from  the  most  trifling  causes.  It  is  a  well  understood  fact 
that  infants  at  the  breast  are  rarely  subject  to  indigestion  Of  a  serious 
character.  The  great  majority  of  dyspeptic  babies  are  found  among  the 
bottle-fed.  That  artificial  feeding  may  be  regarded  as  a  predisposing 
cause  of  indigestion  is  perfectly  rational  when  we  consider  the  difficul- 
ties in  the  production  of  a  synthetic  aliment  suitable  to  the  require- 
ments of  the  infant  stomach  (Chapters  X-XI,  Part  I)  and  the  greater 
liability  of  the  bottle-fed  to  accidental  infection. 

Among  the  conditions  which  affect  digestion  teething  is  often  empha- 
sized. Certain  it  is  that  during  dentition  disturbed  digestion  is  of  more 
frequent  occurrence  than  prior  or  subsequent  to  this  period.  Undoubt- 
edly numerous  other  causes  operate  at  this  time  from  which  the  younger 
infant  is  exempt,  and  to  which  the  more  developed  digestion  of  the  older 
child  is  partly  immune.  Among  these  causes  are  trifling  with  food  not 
properly  in  the  baby's  dietary,  increased  exposure  to  draughts  and 
temperature  changes  which  comes  with  the  creeping  and  toddling  age, 
and  the  greater  opportunity  for  infection  through  the  mouth, — that 
common  receptacle  for  all  objects  within  reach. 

In  older  children  as  in  infants,  malhygiene  plays  the  principal  etio- 
logic  role  in  digestive  disturbances.  Inappropriate  food — as  condiments, 
-entrees,  rich  puddings,  pastries,  and  sweetmeats — is  a  frequent  cause, 
while  overfeeding,  too  rapid  eating,  imperfect  mastication,  and  nerve 
exhaustion  are  of  common  occurrence. 

The  symptoms  of  acute  indigestion  include  abdominal  pain  and  dis- 
tention, elevation  of  temperature  (102°-104°  F.,  39°-40°  C),  headache, 
vomiting,  anorexia,  diarrhoea,  thirst,  coated  tongue,  and  foul  breath. 
The  vomitus  is  usually  acid,  ill  smelling,  and  in  the  infant  may  consist 
of  masses  of  solidified  casein.  The  dejections  are  usually  accompanied 
by  foul  flatus,  and  consist  of  undigested  or  decomposing  food.    In  some 


ACUTE    ENTERITIS  247 

children  there  is  marked  disturbance  of  the  nervous  system,  with  rest- 
lessness, grinding  of  the  teeth,  and  even  delirium.  In  infants  there  may 
be  convulsions. 

The  diagnosis  from  other  acute  disorders  may  frequently  be  made 
from  the  history  of  dietetic  errors  and  from  symptoms  pointing  to  the 
digestive  tract,  although  it  must  be  borne  in  mind  that  the  onset  of  most 
of  the  acute  infectious  diseases  is  accompanied  by  gastro-enteric  dis- 
turbauces.  These  occasionally  act  as  a  determining  cause  of  the  graver 
affections. 

The  prognosis  of  acute  indigestion  is  rarely  serious  if  the  condition 
be  met  by  appropriate  treatment.  Neglected  and  maltreated  cases  may 
result  in  visceral  inflammations,  severe  intoxications,  and  athrepsia. 

In  treating  acute  dyspepsia  we  should  assist  nature  in  getting  rid  of 
the  offending  material  by  prompt  emesis  and  catharsis,  and  allow  the 
stomach  complete  rest  by  withholding  food  until  the  irritation  has  sub- 
sided. The  fever,  pain,  and  nervous  disturbance  will  usually  disappear 
with  thorough  evacuation  of  the  bowels.  Small  doses  of  calomel,  one- 
fifth  to  one-tenth  grain  (0.013-0.0065  Gm.),  with  sodium  bicarbonate  one- 
half  to  one-quarter  grain  (0.032-0.016  Gm.),  should  be  given  every  hour 
until  six  to  ten  doses  have  been  taken.  This  should  be  followed  by  a 
saline  or  a  dose  of  castor  oil.  If  the  vomiting  is  not  excessive  from  the 
beginning,  a  full  dose  of  castor  oil  may  be  administered  at  once.  Its 
action,  if  delayed,  should  be  assisted  by  enemata  of  saline  solution.  If 
vomiting  be  severe  the  stomach  should  be  washed  out  with  a  hot,  weak 
solution  of  bicarbonate  of  soda  and  boiled  water,  ten  grains  to  the  ounce 
(0.65  Gm.-30  C.c).  The  hot-water  bottle  or  weak  mustard  paste,  applied 
over  the  stomach,  may  be  necessary  for  the  relief  of  pain.  The  child 
should  be  kept  in  bed  and  food  should  be  withheld  until  the  subsidence 
of  all  acute  symptoms,  after  which  the  feeding  may  be  cautiously  resumed 
in  attenuated  form  and  reduced  quantity. 

ACUTE   ENTERITIS — SUMMER    DIARRHCEA. 

It  is  too  early  to  claim  that  all  acute  gastro-iutestinal  disturbances  in 
children  are  due  to  toxins  introduced  through  the  mouth.  It  is  possible 
that  such  a  claim  may  never  be  substantiated.  If,  however,  the  theory 
of  food  infection  as  the  prime  etiologic  factor  in  enteric  disorders  be 
proven  valuable  as  a  working  hypothesis  in  their  prevention  and  cure, 
then  it  should  be  accepted  until  displaced  by  more  positive  knowledge. 
A  classification  of  diarrhceal  disorders  on  the  basis  of  pathologic  lesions. 
hoAvever  interesting,  may  well  lie  relegated  to  the  dead-house  where  alone 
their  character  is  demonstrable.  It  is  well  known  that  autopsies  on  chil- 
dren dying  of  diarrhceal  diseases  have  often  been  full  of  surprises  to  the 
pathologist,  not  only  in  regard  to  the  presence  or  absence  of  enteric 
lesions,  but  as  to  their  nature,  location,  and  extent.  The  terms  duodenitis, 
ileitis,  colitis  and  proctitis,  singly  or  hyphenated,  with  their  modifying 
adjectives — functional,  catarrhal,  irritative,  toxic,  infectious,  follicular, 
ulcerative,  or  membranous — are  interesting  and  useful  in  describing  the 


248        DISEASES    OF    THE    GASTRO-ENTEBIC    TRACT 

findings  upon  the  post-mortem  table.  But  since  the  findings  cannot  be 
predicted  with  any  degree  of  certainty  from  the  history  of  the  disease, 
a  classification  based  thereon  can  hardly  be  serviceable  as  a  guide  to 
either  treatment  or  prognosis. 

By  a  sort  of  common  consent,  acute  disorders,  with  diarrhoea  as  the 
principal  symptom,  which  involve  the  small  intestine  have  been  called 
enteritis,  while  those  of  the  large  intestine  are  called  colitis.  In  many 
cases,  no  doubt,  strictly  speaking,  this  would  be  an  unwarrantable  use 
of  the  suffix,  as  he  is  a  bold  pathologist  who  claims  that  all  acute  enteric 
disturbances  resulting  in  diarrhoea  are  inflammatory.  That  acute  intes- 
tinal indigestion  may  result  in  inflammatory  lesions  of  the  bowels  there 
is  not  the  slightest  doubt,  but  no  one  can  determine  the  exact  time  at 
which  the  inflammatory  process  begins.  It  is  fairly  safe  to  assert  that 
almost  all  acute  inflammations  of  the  intestines  begin  with  indigestion, 
and  many  diagnosticians  are  content  to  employ  the  suffix  only  after  the 
third  day  of  continued  fever  and  diarrhoea. 

As  before  stated,  gastric  and  intestinal  indigestion  cannot  clinically 
be  disassociated,  although  the  preponderance  of  the  symptoms  may  point 
more  decidedly  to  one  or  the  other  condition.  Most  frequently,  however, 
gastric  indigestion  precedes  that  of  the  bowel,  and  the  clinical  picture  is 
familiar  in  which  a  gastro-entero-colitis  begins  with  vomiting  and  ends 
with  dysentery. 

Etiology. — The  etiology  of  acute  indigestion  has  been  made  to  include 
congenital  predisposition,  infancy,  and  summer  heat  among  its  predis- 
posing causes.  Improper  feeding,  infections,  and  sudden  refrigera- 
tion are  some  of  the  exciting  causes.  Undoubtedly,  feeble  action  of  the 
digestive  secretion  is  peculiar  to  some  children,  whether  as  an  inherited 
or  acquired  dyscrasia.  Such  children  are  brought  through  the  nursing 
period  with  the  greatest  difficulty.  The  clinical  histories  show  a  con- 
tinuous struggle  in  the  adaptation  of  their  food  to  a  feeble  digestive 
function. 

The  claim  that  normal  infancy  predisposes  to  indigestion  is  unfair 
to  the  infant.  That  his  helplessness  renders  him  peculiarly  susceptible  to 
neglect,  is  self-evident;  so  also  is  his  feeble  resistance  to  infections  to 
which  he  may  be  carelessly  exposed.  Prolonged  summer  heat,  which 
was  formerly  regarded  as  the  principal  exciting  cause  of  digestive 
disturbance,  is  now  allowed  to  rank  among  the  principal  predisposing 
causes.  Endless  statistics  are  available  to  show  the  prevalence  of  diar- 
rhoeal  disorders  in  the  summer  months.  Prolonged  excessive  heat  (over 
80°  F.,  26.6°  C),  with  humidity,  inhibit  digestion  so  that  the  amount 
of  fats  and  proteids  easily  disposed  of  during  temperate  weather,  may 
overwhelm  the  digestive  function  during  the  hottest  days  of  summer. 
Again,  the  heated  term  is  precarious  to  the  neglected  infant  because  of 
the  luxuriant  growth  of  pathogenic  micro-organisms,  and  the  increased 
contamination  and  rapid  decomposition  of  food  with  the  production  of 
dangerous  toxins. 

That  errors  in  feeding  are  the  prime  cause  of  indigestion  is  widely 


ACUTE    ENTERITIS  249 

in  evidence.  These  errors  may  be  divided  into  two  principal  classes, 
first,  in  the  method  of  feeding,  and  second,  in  the  quality  of  food.  To 
the  lirst  class  belong  those  disorders  in  which  a  normal  food  may  cause 
disturbance  by  overingestion,  or  by  irregularity  in  feeding.  To  this  class 
belongs  the  majority  of  disturbances  in  infants  who  nurse  ;it  the  breast. 
A  good  illustration  is  seen  in  the  overingestion  of  normal  breast  milk 
during  the  hot  days  of  summer,  when  the  caloric  requirements  of  infant 
metabolism  would  suggest  a  reduction  in  both  fats  and  proteids.  The 
increased  demand  for  water,  to  make  good  the  deficiency  caused  by  per- 
spiration, draws  the  infant  to  the  breast  as  its  only  known  means  of 
supply.  The  thirst,  already  increased  by  beginning  indigestion,  is  met 
with  an  increased  ingestion  of  unrequired  food  to  the  further  detriment 
of  the  overworked  digestive  function.  Thus  a  vicious  circle  is  estab- 
lished which  soon  results  in  fermentative  changes  in  the  infant's  prima 
via  from  digestive  incompetency.  Irregular  feeding  means  overfeed- 
ing, and  develops  the  factors  of  impaired  lactation,  as  well  as  impair- 
ment of  the  infant's  gastric  and  duodenal  secretions  (Chapter  VI, 
Part  I).  The  frequency  of  indigestion  among  the  breast-fed,  however, 
is  insignificant  compared  with  its  prevalence  among  the  bottle-fed.  The 
dangers  that  lurk  in  artificial  feeding  have  not  only  to  do  with  the 
amount  and  method  of  ingestion,  but  are  in  close  relation  to  the  unsuita- 
bility  of  the  food,  and  to  an  added  and  most  prolific  source  of  danger, — 
namely,  the  increased  liability  to  infections,  not  only  from  accidental 
contamination,  but  from  fermentative  changes  due  to  resident  milk  bac- 
teria and  also  from  their  toxins. 

The  disturbances  due  to  candies,  sweetmeats,  unripe  and  inappro- 
priate fruits,  and  to  other  dietetic  errors  of  childhood,  are  too  familiar  to 
need  mention.  The  possibility  of  introducing  infectious  material  and 
irritant  poisons  in  this  way  adds  greatly  to  the  dangers  of  indiscriminate 
feeding  in  older  children. 

Exposure  to  cold  may  precipitate  an  attack  of  acute  indigestion,  in 
the  absence  of  any  apparent  error  in  diet,  probably  through  changes  in 
the  quality  or  quantity  of  the  digestive  fluids  from  disturbed  circulation. 
Fatigue,  excitement  and  shock  may  interfere  with  the  digestive  process, 
with  resultant  vomiting  or  diarrhoea. 

The  chemico-physics  of  perverted  digestion  is  too  obscure  to  warrant 
dogmatic  description  of  its  functional  pathology.  Broadly  stated,  where 
the  normal  changes  in  the  food  are  incomplete  or  long  delayed,  fermenta- 
tive processes  may  supervene  with  the  production  of  substances  and  gases 
which  irritate  the  intestinal  mucosa  and  cause  an  outpouring  of  mucus 
with  increased  peristalsis.  Putrefactive  changes  in  the  residuum  of  un- 
digested food  may  evolve  toxic  products  which  are  not  only  local  irri- 
tants but  which,  by  absorption  into  the  circulation,  may  produce  general 
symptoms  of  profound  disturbance.  It  is  usually  held  that  the  diarrhoea 
and  vomiting  which  commonly  accompany  acute  indigestion  are  con- 
servative processes  through  which  nature  seeks  relief  from  the  offeuding 
material. 


250         DISEASES    OF    THE    GASTRO-ENTERIC    TRACT 

Symptoms. — Besides  the  vomiting  and  diarrhoea  there  may  be  fever, 
102°  to  105°  F.  (39°-40.5°  C.),  rapid  pulse,  headache,  anorexia,  thirst, 
coated  tongue,  and  colicky  pains.  Tenesmus  frequently  accompanies 
the  exaggerated  peristalsis  which,  with  increased  secretions,  contributes 
to  the  diarrhoea.  In  infants  the  prostration  is  marked,  as  shown 
by  the  drawn,  pallid  features,  and  general  muscular  weakness.  The 
urine  is  scanty  in  proportion  to  the  loss  of  fluids  from  the  bowel,  and 
may  contain  albumin  and  occasionally  hyaline  and  fine  granular  casts. 
Bile  may  stain  the  urine,  if  the  catarrhal  condition  involve  the  duodenum 
from  occlusion  of  the  common  duct,  in  which  case  icterus  is  present.  In 
mild  attacks  there  is  restlessness,  disturbed  sleep,  and  night  terrors. 
In  more  severe  intoxication  there  may  be  •  delirium  and  convulsions  or 
coma  with  death,  a  not  rare  termination  in  delicate  infants. 

The  diarrhoea  may  not  be  marked  at  first — in  fact,  there  may  be  con- 
stipation with  the  initial  vomiting — but  the  movements  soon  increase  in 
frequency  and  follow  closely  the  ingestion  of  food,  numbering  from  four 
to  twelve  a  day.  As  the  disease  progresses  the  vomiting  may  diminish  or 
subside  unless  excited  by  injudicious  feeding.  At  first  the  stools  may 
differ  from  the  normal  only  in  being  more  liquid  and  abundant  and  in 
their  offensive  odor.  They  change  as  the  indigestion  continues,  varying 
in  consistency  and  color  which,  in  infants,  usually  becomes  green  with 
whitish  or  yellowish  curds  and  particles  of  tough  casein  resembling 
broken  kernels  of  sweet  corn.  Tufts  of  mucus  and  soapy  fats  may 
be  mixed  with  the  "chopped-spinaeh"  stools,  or  the  movements  may 
be  slimy,  watery,  or  yeasty  from  the  gases  of  fermentation.  Their  acid 
character  causes  tenesmus  and  pain,  which  is  relieved  by  the  evacuation, 
while  intertrigo  and  excoriation  of  the  buttocks  may  result.  Fatty  acids 
may  be  present.  The  microscope  may  show  numbers  of  intestinal  bacteria 
and,  if  cereals  enter  into  the  food,  the  iodine-test  will  give  the  blue  reac- 
tion of  starch.  The  green  stools  of  infancy,  due  to  the  chromogenic  bacil- 
lus (Lesage),  are  decolorized  by  the  addition  of  a  drop  of  nitric  acid. 
When  this  color,  however,  is  due  to  biliary  salts,  the  green  changes  to 
pink,  purple,  or  violet  on  the  addition  of  the  acid.  Green  stools  are 
rarely  seen  in  children  after  the  third  year. 

The  prognosis  in  mild  attacks  of  acute  indigestion  under  favorable 
conditions,  if  treated  early,  is  good,  but  so  much  depends  upon  the  en- 
vironment, the  stage  of  the  disorder,  thermic  and  atmospheric  conditions, 
a?e  of  the  child  and  the  possibility  of  virulent  bacteria  having  invaded 
the  mucosa  through  erosions  of  the  epithelium,  that  the  prognosis  should 
be  guarded.  Infants  at  the  breast  respond  so  much  more  readily  to 
corrective  measures  than  do  those  brought  up  on  the  bottle,  that  the 
difference  in  tractability  is  equivalent  to  two  different  types  of  disease. 

Treatment. — Two  indications  are  paramount.  First,  stop  the  feed- 
in  g ■-.  second,  clean  out  the  prima  via.  A  full  dose  of  castor  oil  may 
oe  given,  or  if  not  tolerated,  calomel,  one-fifth  to  one-half  a  grain  (0.013- 
0.032  Gin.),  with  soda  bicarbonate,  one-half  to  two  grains  (0.032-0.13 
Gm.i,  may  be  given  every  hour  for  four  or  five  hours,  after  which  one- 


ACUTE    ENTERITIS  251 

half  to  one-quarter  of  that  amount  may  be  given  every  hour  or  two  and 
continued  at  lengthening  intervals  for  a  day  or  two.  Ordinary  cases  of 
indigestion  will  yield  to  this  simple  treatment.  For  the  food,  water 
must  be  substituted  for  twenty-four  hours,  after  which  nursing  may  be 
resumed  with  strict  attention  to  hygiene.  If  bottle-fed,  the  strength  of 
the  food  must  be  reduced  by  the  addition  of  water  or  cereal  gruel.  The 
errors  in  diet  or  method  of  feeding  responsible  for  the  attack  must  be 
sought  for  and  corrected,  and  the  mother  or  nurse  thoroughly  instructed 
in  the  essential  details  of  aseptic  hygiene.     (Chapter  XII,  Part  I.) 

Instead  of  recovery  in  response  to  withdrawal  of  food  and  cleaning 
out  of  the  bowels,  vomiting,  fever  and  diarrhoea  may  persist,  the  stools 
becoming  watery  and  frequent,  with  particles  of  undigested  food  or  flakes 
•of  casein.  They  may  be  fetid  and  musty,  or  slimy  and  odorless,  with 
pinkish  Hecks  or  gouts  of  brighter  blood.  The  abdomen  is  retracted  or 
distended,  the  tissues  flabby  from  loss  of  adipose  and  from  muscular 
weakness.  There  may  be  cervical  rigidity,  head-rocking,  exaggerated 
reflexes,  strabismus'  or  semicoma,  suggestive  of  meningitis.  The  infant 
may  be  fretful  or  apathetic.  The  dry  mouth,  pallid  skin,  pinched  fea- 
tures, hollow  orbits,  and  depressed  fontanelle  with  the  foregoing  symptoms 
point  to  acute  gastro-intestinal  infection,  in  the  perpetuation  of  which 
bacteria  play  an  important  role  regardless  of  the  primary  cause  of  the 
disturbance.  That  the  bacteria,  pre-existent  in  the  bowel,  rapidly  multiply 
and  assume  virulent  pathogenic  activity  under  conditions  rendered 
favorable  by  indigestion,  there  is  every  reason  to  believe.  Solutions  of 
continuity  of  the  epithelium  allow  entrance  to  the  mucosa  for  these  or- 
ganisms and  their  toxins,  which  thence  find  their  way  into  the  lymph 
channels  and  blood-vessels.  They  even  invade  remote  organs  and  tissues 
with  resulting  lesions  peculiar  to  the  location,  such  as  pneumonia,  pleur- 
isy, endocarditis,  meningitis,  or  extensive  adenitis  of  the  mesentery  and 
lymph-nodes  of  the  gut  itself.  A  variety  of  resident  organisms  may  be- 
come virulent  and  assume  pathogenic  activity  under  these  circumstances, 
such  as  the  streptococcus  and  members  of  the  coli  group,  while  the  casein 
ferments — such  as  the  bacillus  subtilis,  bacillus  mesentericus,  and  tyro- 
trix  tenuis — are  found  only  in  the  stools  of  infants  fed  on  cow's  milk. 
Such  infections  have  been  called  endogenous,  and  probably  to  this  class 
belong  those  disturbances  ascribed  to  autoinfection,  lithasmia,  etc.,  which 
occur  sporadically  without  apparent  dietetic  error  or  other  explainable 
cause. 

In  contrast  to  the  above  are  ectogenous  infections,  of  which  cow's 
milk  is  the  most  prolific  source.  In  addition  to  the  bacterial  content,  old 
milk  may  convey  a  poison  (tyrotoxicon)  which  is  capable  of  causing 
the  most  violent  forms  of  intoxication,  and  against  which .  when  once 
formed  in  milk,  no  amount  of  sterilization  will  avail.  Many  kinds  of 
bacteria  or  their  toxins  gain  ingress  from  without  and  induce  or  contrib- 
ute to  gastro-enteric  morbidity, — as  the  proteus  vulgaris,  streptococcus, 
peptonizing  bacteria,  bacillus  pyoeyaneus,  colon  bacillus,  staphylococcus, 
and  many  varieties  of  saprophytic  organisms.     A  variety  of  recently 


252         DISEASES    OF    THE    GASTEO-ENTEBIC    TEACT 

isolated  organisms,  closely  identified  with  the  bacillus  dysenteric  of  Shiga, 
have  claimants  for  the  chief  etiologic  role  in  the  enteritides  of  children, 
but  thus  far  their  constant  presence  has  not  been  demonstrated  nor  is 
the  type  of  symptoms  or  lesions  constant  with  which  they  are  associated. 
Whatever  the  future  may  reveal,  for  the  present,  at  least,  the  etiology  of 
summer  diarrhoea  in  its  protean  forms  and  lesions,  must  be  regarded  as 
multiplex  and  more  or  less  obscure  as  to  the  true  relationship  of  its 
numerous  factors. 

Indigestion,  feeble  resistance,  contaminated  food,  and  hot  weather, 
are  recognized  causes  in  sporadic  enteritis,  while  its  prevalence  in  epi- 
demic form  in  families  and  tenement-houses,  and  in  institutions  where 
large  numbers  of  children  are  in  close  relation,  savors  strongly  of  contact 
transmission  of  the  morbific  agents,  quite  suggestive  of  the  manner  of 
typhoid  fever  transmission. 

From  the  lesions  found  post-mortem  it  is  evident  that  no  portion  of 
the  gastro-enteric  mucosa  is  exempt,  although  the  most  vulnerable  areas 
below  the  stomach  are  the  lower  ileum  and  the  colon, — hence  the  term 
entero-colitis,  as  generally  applied. 

Even  in  severe  cases  of  short  duration  there  may  be  only  a  general 
hyperemia  of  the  mucosa  not  at  all  proportionate  to  the  severity  of  the 
symptoms.  In  prolonged  enteritis  erosions  of  the  mucous  membrane  and 
many  minute  hemorrhages  are  usually  seen,  and  the  solitary  follicles 
and  Peyer's  patches  may  show  extensive  hyperplasia  or  even  ulceration. 
Exceptionally  ulcerative  lesions  occur  early  (Fig.  136),  but  as  before 
stated,  there  is  no  constant  relation  between  the  severity  of  the  symp- 
toms, their  duration,  and  the  anatomical  lesions  of  the  bowels. 

Pseudomembranous  lesions  are  occasionally  found,  consisting  of  in- 
flammatory exudate,  epithelium,  blood-cells  and  bacteria.  These  mem- 
branes occur  in  circumscribed  patches,  or  may  cover  a  considerable 
portion  of  the  ileocolic  mucosa  to  which  it  is  firmly  adherent.  Beneath 
the  pseudomembrane  the  inflammation  may  involve  the  entire  structure 
of  the  bowel,  and  even  appear  as  a  circumscribed  exudate  on  the  peri- 
toneal surface. 

Diagnosis. — The  diagnosis  of  gastro-enteritis  must  be  made  from  the 
mode  of  onset  and  history  of  symptoms,  but  mainly  from  the  character 
of  the  stools.  From  the  acute  exanthems,  pneumonia,  or  influenza  which 
are  frequently  ushered  in  by  vomiting  and  diarrhoea,  a  positive  diagnosis 
must  often  wait  upon  the  development  of  characteristic  signs  or  the 
eruptions  of  the  specific  disease.  It  should  be  borne  in  mind  that  pneu- 
monia is  a  frequent  complication  of  a  later  stage  of  entero-colitis. 
Usually,  however,  the  gastro-enteric  disturbance  subsides  as  the  infec- 
tion develops,  to  which  it  is  secondary.  Typhoid  fever,  in  the  atypical 
forms  occasionally  encountered  in  infancy,  may  present  many  difficul- 
ties. Usually  the  vomiting  is  less  persistent  in  proportion  to  the  high 
temperature  which  in  children  may  attend  the  onset  of  that  disease,  and 
the  common  accompaniment  of  enlarged  spleen  and  liver  may  aid  in 
differentiation  before  the  time  for  rose  spots  and  Widal  reaction.     The 


Fig.  136.— Ulceration  of  Peyer's  patch.    Infant  of  11  months.    Death  on  the  fourth  day,  with  symptoms 

of  meningitis.     Brain  negative. 


ACUTE    ENTEROCOLITIS  253 

cerebral  and  nervous  symptoms  of  acute  gastro-enterie  disease  may  so 
closely  simulate  meningitis  as  to  delay  positive  diagnosis  £or  several 
days.  Indeed,  the  post-mortem  demonstration  of  intestinal  lesions  in 
children  dying  from  a  supposed  meningitis  is  not  of  rare  occurrence 
(Fig.  136).  A  complete  history  of  the  case  rarely  shows  bulging  of  the 
fontanelle  in  entero-colitis,  and  constipation,  rather  than  diarrhoea,  is  the 
rule  in  meningitis.  The  encephaloid  symptoms,  frequently  seen  towards 
the  termination  of  fatal  colitis,  are  usually  due  to  cerebral  anaemia  which 
the  condition  of  the  fontanelle  and  an  examination  of  the  ocular  fundus 
should  confirm. 

Entero-colitis  is  occasionally  mistaken  for  intussusception  of  the 
bowel.  The  absence  of  pyrexia  in  the  early  stage,  marked  prostration, 
severe  paroxysmal  pain,  early  mucoid  bloody  stools  free  from  fecal  mat- 
ter and,  above  all,  the  presence  of  a  tumor,  usually  in  the  left  iliac 
region,  should  render  the  diagnosis  of  intussusception  plain. 

Prognosis. — The  prognosis  in  acute  gastro-enterie  disorders  should 
always  be  guarded.  The  age  of  the  patient,  the  method  of  feeding, 
whether  natural  or  artificial,  previous  physical  condition,  the  stage  of 
the  disease  when  first  seen,  the  season  of  the  year,  the  hygiene  of  the 
environment,  the  intelligence  of  the  nurse,  and  the  apparent  exciting 
cause, — all  must  be  taken  into  consideration  as  important  factors  in  the 
tractability  of  the  disease.  Some  children  exhibit  from  the  beginning 
unmistakable  evidences  of  a  virulent  type  of  infection,  as  in  the  so- 
called  cholera  infantum.  Exacerbations  of  temperature,  after  the  sub- 
sidence of  acute  early  symptoms,  should  always  be  regarded  with  appre- 
hension as  reinfection  is  frequent,  even  during  convalescence.  The  pro- 
gressive character  of  enteric  disorders  must  always  be  kept  in  mind  and 
the  possibility  of  the  supervention  of  follicular,  ulcerative  and  mem- 
branous lesions  upon  an  apparently  mild  case  of  indigestion  should 
keep  prognostication  in  abeyance.  The  symptoms  of  acute  entero-colitis 
may  subside  with  proper  treatment  in  from  five  to  ten  days,  but  more 
frequently  the  diarrhoea  will  be  prolonged  into  the  third  week. 

Treatment. — The  treatment  must  fully  meet  three  indications :  first, 
to  remove  the  cause ;  second,  to  counteract  the  effects ;  and,  third,  to 
maintain  strength.  Although  the  immediate  cause  may  be  obscure,  in- 
digestion is  so  intimately  connected  with  the  perpetuation  of  the  morbid 
process  that  food  must  be  immediately  withdrawn,  even  though  it  may 
not  contain  the  primary  morbific  agent.  The  possibility  of  increased 
infection  through  substances  introduced  into  the  mouth  is  so  great  that, 
in  the  words  of  Cromby,  one  must  "  stand  guard  before  the  digestive 
tube."  All  the  predisposing  and  contributing  influences  must  receive 
attention.  Torrid  summer  heat  should  call  for  immediate  removal 
of  the  child,  when  possible,  to  the  sea-shore,  lake-side,  or  mountains. 
For  the  children  of  unsanitary  homes  and  congested  districts,  many  of 
our  great  cities  have  public  parks,  floating  hospitals,  and  sanatoria  on 
piers,  where  the  heat  is  tempered  by  large  bodies  of  water  and  the  air 
is  pure.     The  depressing  effects  of  atmospheric  heat  may  be  somewhat 


254         DISEASES    OP    THE    GASTRO-ENTERIC    TRACT 

ameliorated  by  lowering  the  temperature  of  the  sick-room  by  a  generous 
use  of  tubs  of  broken  ice  and  the  play  of  electric  fans,  when  better 
means  are  not  available. 

The  danger  of  reinfection  should  lead  to  a  conscientious  care  of  all 
discharges.  Soiled  napkins  and  clothes  should  be  immediately  placed  in 
a  can  with  a  tight  cover,  until  inspected  by  the  physician.  After  this 
they  should  be  placed  in  some  disinfecting  solution,  as  bichloride  of 
mercury,  1  :  2000,  before  washing  and  boiling.  Flies  must  be  excluded 
by  screens  at  windows  and  doors,  and  netting  over  the  baby-carriage. 
As  a  rule,  the  open  air  is  preferable  throughout  the  day.  All  water 
used  about  the  patient  should  be  sterilized  and  the  source  of  ice  should 
be  above  suspicion.  Much  infected  and  infectious  material  in  the  prima 
via  may  be  removed  by  free  catharsis,  lavage  and  colonic  flushing.  These 
should  be  immediately  resorted  to,  first,  by  the  administration  of  a  full 
dose  of  castor  oil  which,  if  not  well  borne  by  the  stomach,  may  be  re- 
placed by  calomel,  one-tenth  to  one-fourth  grain  (0.0065-0.016  Gm.)  with 
sodium  bicarbonate,  one  to  two  grains  (0.065-0.13  Gm.),  given  every 
hour  or  oftener  for  from  six  to  ten  doses,  after  which  the  quantity  may 
be  reduced  and  the  interval  lengthened  according  to  the  amelioration  of 
the  symptoms  and  the  character  of  the  stools.  The  stomach*,  especially 
if  vomiting  persists,  may  be  washed  out  with  sterilized  water  or  weak 
boric  acid  or  bicarbonate  of  soda  solution,  one  drachm  to  the  pint  (1  Gm- 
y2  litre),  once  or  twice  in  the  twenty-four  hours.  Frequently  one  or  two 
washings  will  suffice.  In  older  children,  where  the  introduction  of  the 
tube  is  impracticable,  copious  draughts  of  warm  sterilized  water  con- 
taining sodium  bicarbonate  may  be  given,  thus  cleansing  the  stomach  by 
emesis.  High  colonic  flushing  not  only  rids  the  lower  bowel  of  irritating 
and  infectious  material,  lessening  the  danger  of  early  lesions  of  the 
mucosa,  but  induces  a  free  discharge  of  the  contents  of  the  small  intes- 
tines, thus  diminishing  the  intoxication  from  absorption.  When  we  con- 
sider the  acrid  character  of  the  alvine  discharges,  as  seen  in  their  effects 
upon  the  unbroken  integument  about  the  anus  and  buttocks,  the  role 
played  by  this  agency  in  causing  erosions  of  the  intestinal  mucosa  (the 
most  serious  lesions  of  enterocolitis),  is  so  apparent  that  the  value  of 
colonic  flushing  needs  no  further  emphasis.  The  water  used  for  this 
purpose  may  be  simply  sterilized  or  contain  boric  acid  or  bicarbonate 
of  sodium  and  should  be  used  copiously.  From  two  to  six  pints  (1-3 
litres),  once  to  thrice  daily,  may  not  be  too  much  in  the  early  stage  of  a 
severe  case.  Besides  its  detergent  effect,  enteroclysis  satisfies  the  demand 
of  the  tissues  for  water,  so  necessary  in  the  depletion  of  the  body  fluid 
by  diarrhoea.  Again,  the  increased  metabolism  of  intoxication,  with 
diminished  normal  alimentation,  quickly  develops  a  paucity  of  alkali  in 
the  circulating  fluids  and  a  condition  of  subalkalinity  unfavorable  to 
constructive  metamorphosis  supervenes.  Hence  the  need  of  sodium 
chloride  and  sodium  bicarbonate  by  enteroclysis. 

The  results  of  efforts  to  neutralize  the  infection  of  the  alimentary 
tract  by  drugs  do  not  warrant  their  extensive  use,  although  empiricism 


ACUTE    ENTEEOCOLITIS  255 

and  theoretical  reasoning  have  furnished  a  bosl  of  agents  for  this  pur- 
pose and  many  eminent  practitioners  still  cling  to  their  Balol,  resorcin, 
naphthol,  salicylates,  sulphocarbolates,  and  similar  preparations.  Next 
to  calomel,  which,  undoubtedly,  has  some  antiseptic  value,  bismuth  bud- 
nitrate,  subcarbonate,  or  subgallate  has  been  found  valuable  in  diminish- 
ing irritability  of  the  gastro-intestinal  tract.  After  positive  assurance 
of  its  freedom  from  arsenic,  bismuth  in  doses  of  from  three  to  ten  grains 
(0.2-0.65  Gm.),  according  to  age,  sin  mi  Id  be  given  every  half  hour  until 
the  mucosa  is  thoroughly  coated  with  the  drug.  This  may  be  indicated 
by  the  appearance  of  black  powder  in  the  stools. 

For  fever  and  restlessness  tepid  sponging  should  be  employed.  A 
little  alcohol  may  be  added  to  the  water  for  its  refrigerant  effect.  If 
there  be  much  cerebral  excitement  an  ice-cap  may  be  employed,  and  if 
convulsions  threaten,  bromide  of  sodium,  five  to  ten  grains  (0.3-0.65 
Gm.),  with  possibly  the  addition  of  two  to  five  grains  (0.13-0.3  Gm.) 
of  chloral  in  an  ounce  (30  C.c.)  of  water  may  be  administered  per  rec- 
tum, after  the  return  of  a  colonic  flushing,  where  it  should  be  retained  by 
pressure  on  the  anus  until  absorbed.  With  high  temperature  and  cold 
extremities,  sinapisms  should  be  applied  to  the  hands  and  feet.  For 
severe  colic  and  exaggerated  peristalsis,  opium  is  invaluable  but  must 
be  used  with  great  caution  and  never  until  the  contents  of  the  intestinal 
tract  have  been  thoroughly  evacuated.  Much  harm  will  follow  the  too 
early  or  injudicious  use  of  this  drug,  and  great  benefit  may  accrue  from 
its  justifiable  exhibition.  It  should  rarely  be  given  by  mouth  and  never 
in  combination  with  other  agents.  Administration  by  rectum  in  half 
an  ounce  (15  C.c.)  of  boiled  starch,  after  a  thorough  cleansing  of  the 
bowel,  is  the  most  eligible  method.  The  dose  of  the  tinctura  opii  deo- 
dorata  may  be  from  one  to  two  minims  (0.065-0.13  Gm.)  to  a  child  of 
one  year  and  may  be  repeated  every  two  hours  until  the  tormenting 
tenesmus  is  quieted.  No  greater  error  obtains  than  misguided  efforts  to 
"cork  up"  the  bowels.  The  safety  of  the  patient  depends  upon  free 
evacuation,  hence  in  early  cessation  of  diarrhoeal  movements,  with  con- 
tinued symptoms  of  intoxication,  small  doses  of  castor  oil  or  oft-repeated 
doses  of  calomel  should  be  resumed  to  secure  bowel  movements. 

A  mistake  too  frequently  made  is  that  of  treating  the  diarrhoea  and 
forgetting  the  patient.  The  prostration  and  inanition  consequent  upon 
general  infection  and  arrested  assimilation  call  for  early  supporting 
measures  and  nutrition  must  be  maintained.  In  severe  cases  feeding  by 
the  mouth  is  worse  than  useless,  as  digestion  is  inhibited  and  the  aliment 
but  furnishes  material  for  fermentation  and  bacterial  growth.  Water 
only  should  be  given  by  the  mouth  for  the  first  twenty-four  hours  or  for 
a  longer  period,  if  necessary.  Nutrient  enemata  may  be  administered 
once  in  three  or  four  hours,  preferably  after  a  movement  and  always 
after  a  colonic  flushing,  and  should  be  retained  by  pressure  on  the  anus. 
With  the  subsidence  of  vomiting  and  improvement  in  the  dejections,  feed- 
ing by  the  mouth  may  be  attempted,  first  with  albumin-water  to  which 
a  little  salt  is  added,  or  barley-water  followed  by  oatmeal-gruel  thor- 


256        DISEASES    OF    THE    GASTROENTERIC    TRACT 

oughly  cooked  and  strained,  and  partly  dextrinized  by  the  addition  of  a 
teaspoonful  of  malt  extract  to  every  four  onnces.  The  quantity  at  first 
must  be  very  small — from  one  to  three  teaspoonfuls  every  hour — and 
may  be  gradually  increased  with  lengthening  intervals  according  to  tol- 
eration. Later,  sterilized  whey  may  be  added,  but  milk  should  be  with- 
held until  convalescence  is  well  established  and  then  given  only  in  at- 
tenuated modifications.  These  children  require  watching  during  the  rest 
of  the  summer  and  may  not  be  able  to  resume  milk  diet  during  that 
time.  The  common  error  lies  in  the  too  early  return  to  milk  feeding. 
Good  cereal  preparations  afford  their  greatest  service  as  substitutes  for 
milk  in  these  cases.  In  breast-fed  infants  the  mammary  secretion  should 
be  maintained  by  a  regular  use  of  the  breast  pump  during  the  enforced 
fast,  and  a  return  to  normal  feeding  in  these  cases  may  with  safety  be 
made  much  earlier  than  in  the  bottle-fed  class.  Care  is  necessary  that 
the  nursling  be  not  returned  to  full  diet  at  first.  Water  should  be  sub- 
stituted before  nursing  for  at  least  half  the  meal  for  a  few  days.  The 
act  of  suckling  should  be  prolonged  by  interruption  and  compression  of 
the  nipple,  so  that  the  food  be  slowly  ingested.  The  remainder  in  the 
breast  should  be  withdrawn  by  a  pump. 

The  diet  of  older  children  in  convalescence  should  consist  principally 
of  cereal  gruels,  partly  dextrinized  by  thorough  cooking  and  the  addition 
of  malt  extract,  the  better  class  of  proprietary  foods,  small  amounts  of 
expressed  raw  meat  juice,  and  soft-boiled  or  poached  eggs.  Toast  or 
zwieback  may  be  added.  Fruits  and  vegetables  must  be  avoided  during 
hot  weather,  although  baked  potatoes  and  well  boiled  rice  may  be 
given.  Meats  should  be  interdicted,  and  milk,  even  thoroughly  sterilized, 
must  be  used  with  great  caution  during  the  hot  weather,  or  until  full 
recovery. 

If  the  atttack  be  prolonged,  great  prostration  may  ensue  with  weak 
and  irregular  heart  action  and  threatened  collapse.  In  this  case  stimu- 
lants are  indicated.  Brandy,  both  as  a  stimulant  and  a  food,  is  the 
most  eligible  and  may  be  given  in  doses  of  five  to  twenty  drops,  accord- 
ing to  age,  diluted  with  eight  to  ten  times  the  amount  of  water.  If  con- 
traindicated,  or  vomiting  is  induced,  the  brandy  or  its  equivalent  in 
cologne  spirits  may  be  given  per  rectum  or  hypodermically,  although  by 
the  latter  means  only  in  extreme  cases. 

Hypodermoclysis  of  normal  salt  solution  may  sustain  the  heart  when 
absorption  from  the  bowel  is  deficient.  From  four  to  six  drachms  (15- 
23  C.c),  to  which  from  one-fourth  to  one-half  of  a  grain  (0.016-0.032 
Gm.)  of  caffeine  citrate  is  added,  may  be  given  to  a  young  infant  at  one 
injection. 

In  mucoid  or  bloody  stools,  indicative  of  extensive  lesion  of  the  lower 
bowel,  weak  solutions  of  tannic  acid  may  be  introduced  through  the 
long  tube,  or  an  emulsion  of  subgallate  of  bismuth,  two  or  three  drachms 
(7.5-11.5  C.c.)  to  as  many  ounces  (60-90  C.c.)  of  mucilage  of  acacia 
may  be  administered  in  the  same  way  every  three  or  four  hours,  if 
necessary. 


CHOLERA    INFANTUM  257 

CHOLERA    INFANTUM. 

A  form  of  acute  intestinal  intoxication,  although  nosologically  be- 
longing with  the  acute  infectious  diseases,  is  taken  up  here  because  of 
its  intimate  clinical  association  with  gastro-enteritis.  The  differentiation 
between  cholera  infantum  and  severe  cases  of  gastro-enteritis  is  not 
always  clear.  The  diagnosis  quite  frequently  depends  upon  the  early 
fatality.  Much  difference  of  opinion  prevails  as  to  the  frequency  of 
cholera  infantum  and  the  percentage  of  its  mortality.  A  most  eminent 
American  pediatrician  recently  declared  in  a  public  lecture  that  he  had 
met  with  but  three  undoubted  cases,  all  of  which  were  fatal,  while 
another  equally  eminent  authority  in  an  adjoining  city  speaks  of  cholera 
infantum  as  not  of  such  rare  occurrence  and  places  the  mortality  at  66 
per  cent.  The  etiology  of  the  disease  is  still  unknown,  although  it  oc- 
casionally develops  during  the  course  of  enterocolitis.  It  may  be  pre- 
ceded by  a  mild  attack  of  indigestion,  or  may  occur  in  an  infant  appa- 
rently in  the  best  of  health.  Cholera  infantum  is  undoubtedly  an  acute 
infectious  disease  producing  early  and  pronounced  systemic  intoxica- 
tion, with  vomiting  and  diarrhoea  as  the  chief  and  constant  symptoms. 
Its  etiology  is  intimately  associated  with  milk  feeding  and  hot  weather. 
Babies  nourished  exclusively  at  the  breast  seem  to  be  exempt. 

Symptoms  and  Course. — The  onset  is  usually  abrupt,  beginning  with 
vomiting  which  is  persistent,  and  fever  which  may  reach  103°  to  107°  F. 
(39.5°-41.5°  C.)  in  the  rectum,  accompanied  or  followed  in  a  few  hours 
by  choleraic  diarrhoea,  which  rapidly  drains  the  body  of  fluids.  After 
the  first  few  movements  the  copious  stools  are  little  more  than  colored 
serum  which  the  napkin  absorbs  like  urine  and  gives  off  first  a  putre- 
factive and  later  a  musty  odor.  From  the  first  the  prostration  is  pro- 
found, with  rapid  emaciation,  so  that  in  a  few  hours  a  plump  infant 
may  show  the  pinched,  pallid  features,  lustreless,  sunken  eyes  with 
rapidly  gathering  film,  drawn  mouth,  depressed  fontanelle  and  overriding 
bones  of  profound  collapse.  The  extremities  and  superficies  are  cold 
and  corpse-like,  while  the  thermometer  in  the  rectum  registers  a  tem- 
perature of  107°  F.  (41.5°  C).  The  abdomen  becomes  flattened;  the 
respiration  shallow  and  sighing,  or  it  may  assume  the  Cheyne-Stokes 
type ;  the  feeble  cry  is  reduced  to  a  whine  or  moan,  while  apathy  deepens 
into  fatal  coma,  and  death  may  occur  with  or  without  convulsions,  fre- 
quently within  twenty-four  hours  from  the  beginning  of  the  attack. 
Occasionally  death  is  postponed  for  two  or  three  days,  and  rarely  a  case 
recovers. 

Pathology. — Post-mortem  examinations  show  no  anatomic  lesions  suffi- 
cient to  explain  the  severity  of  the  symptoms.  The  gastro-enteric  mucosa 
is  hyperamiic,  with  minute  hemorrhages  and  areas  denuded  of  epi- 
thelium. The  liver  may  show  slight  fatty  degeneration.  The  kidneys 
and  heart  present  beginning  degenerative  changes,  and  the  lungs  show 
areas  of  collapse  and  hypostatic  pneumonia  in  the  dependent  portions. 
The  blood  in  the  vessels  is  inspissated  and  shows  tardy  coagulability 

17 


258         DISEASES    OF    THE    GASTROENTERIC    TRACT 

During  life  the  erythrocytes  may  reach  seven  millions  or  even  eight 
millions  per  C.c,  and  there  is  usually  a  disproportionate  leucocyto- 
sis,  occasionally  amounting  to  eighty  thousand  per  C.c,  with  a  high 
percentage  of  polymorphonuclear  neutrophiles.  The  picture  is  not 
only  one  of  extreme  oligemia  sicca,  but  also  of  a  virulent  systemic 
intoxication  with  cardiac  depression  and  paralysis  of  the  vasomotor 
nerve-centres  resulting  in  local  congestions  and  transudation  of  serum 
into  the  intestines. 

Treatment. — The  sudden  onset  and  rapid  progress  of  cholera  infan- 
tum leaves  but  little  time  for  the  employment  of  remedial  measures,  fre- 
quently successful  in  gastro-intestinal  intoxication  of  milder  type.  In 
cases  which  develop  more  gradually  as  in  those  preceded  by  acute  gastro- 
enteric indigestion,  early  treatment  as  outlined  in  the  preceding  pages, 
it  is  believed,  might  avert  the  more  severe  effects  by  early  elimination  of 
the  morbific  agent.  The  indications  for  treatment  in  addition  to  those 
given  under  Acute  Gastroenteritis,  are,  first,  to  counteract  the  pro- 
found depression ;  second,  to  overcome  the  tendency  to  blood  concentra- 
tion by  increasing  the  volume  of  the  fluids  in  the  body.  The  question 
of  food  in  the  first  forty-eight  hours  is  immaterial,  as  no  digestion  or 
assimilation  is  possible  in  the  disturbed  state  of  the  circulation.  Brandy 
should  be  administered  from  the  beginning,  or  small  doses  of  iced  cham- 
pagne. Absorption  from  the  stomach  and  intestines  is  questionable,  and 
the  more  efficient  method  is  by  hypodermic  injection.  Digitalin  and 
citrate  of  caffeine  may  be  given  in  the  same  way  to  sustain  the  heart. 
In  the  algid  state  the  empty  superficial  vessels  and  failing  pulse  would 
suggest  the  use  of  nitroglycerin,  which  should  be  frequently  repeated  in 
doses  of  from  one  two-hundredth  to  one  one-hundredth  of  a  grain 
(0.0003-0.00065  Gm.).  One-fiftieth  to  one  one-hundredth  of  a  grain 
(0.0013-0.00065  Gm.)  morphine  with  atropine,  one  five-hundredth  to  one 
one-thousandth  (0.00013-0.00006  Gm.)  for  a  child  of  one  year,  hypoder- 
mically,  is  considered  the  most  valuable  therapeutic  agent.  This  may  be 
repeated  every  hour  or  two  for  the  relief  of  vomiting  and  purging  and 
to  sustain  the  action  of  the  heart.  Stupor  or  coma  contraindicates  the 
use  of  opium.  The  similarity  of  the  symptoms  between  choleriform  in- 
toxication and  those  which  follow  ablation  or  sudden  functional  arrest 
of  the  suprarenal  glands  has  led  to  the  suggestion  of  the  employment  of 
the  suprarenal  extract  in  cholera  infantum.  In  view  of  the  desperate 
character  and  high  mortality  of  this  disease,  the  tentative  employment  of 
this  agent  seems  justifiable. 

Of  equal  importance  to  the  need  of  stimulation  is  the  demand  for 
water  in  the  drained  tissues.  Ice-water  in  small  quantities  should  be 
given  frequently  by  mouth.  Enteroclysis  of  sterilized  water  containing 
sodium  bicarbonate  and  chloride,  each  a  drachm  to  the  quart  (4  Gm. 
to  the  litre),  should  be  freely  employed.  Hypodermoclysis  of  normal 
salt  solution  from  four  to  six  drachms  (15-22.5  C.c.)  should  be  given 
every  one  or  two  hours,  depending  upon  the  frequency  of  the  alvine  dis- 
charges.   Hot  baths  or  packs  are  indicated  in  the  algid  state  to  promote 


CHRONIC    GASTRITIS  259 

superficial  circulation.     This  may  be  aided  by  sinapisms  applied  to  the 
extremities. 

CHRONIC   GASTRITIS — CHRONIC   GASTRIC   CATARRH  ;     CHRONIC   DYSPEPSIA. 

Following  an  attack  of  acute  gastritis  that  has  been  indifferently 
treated  or  allowed  to  relapse  from  neglect  of  dietary  precautions,  a  sub- 
acute or  chronic  dyspepsia  may  develop.  This  condition  may  also  develop 
insidiously  in  babies  whose  food  is  faulty,  as  in  the  continued  excess  of 
some  constituent,  such  as  fat.  In  older  children  repeated  slight  viola- 
tions of  dietary  hygiene  may  gradually  lead  up  to  an  inadequacy  of  gas- 
tric function  so  that  by  degrees  the  incomplete  digestion  results  in  pro- 
ducts which  are  irritative. 

A  catarrhal  condition  of  the  mucosa  follows  with  not  only  interfer- 
ence in  the  secretion  of  normal  digestive  fluids  but  with  fermentative 
changes  in  the  excess  of  mucus  thus  produced.  Congestion,  both  active 
and  passive,  in  the  vessels  of  the  mucosa  favors  the  morbid  process  until 
structural  alterations  are  seen,  such  as  cellular  infiltration,  obliteration 
of  glandular  structures,  and  occlusion  of  tubules.  Occasionally,  though 
rarely  in  infancy,  there  may  be  increase  in  the  interstitial  tissue  so  that 
the  gastric  mucosa  presents  some  fibrosis,  a  chronic  adenitis  and  an  ad- 
vanced catarrhal  condition,  marked  by  excess  of  mucus.  There  is 
atrophy  of  the  muscular  structures  and  frequently  dilatation  of  the 
stomach,  due  to  continued  pressure  from  accumulations  of  food,  mucus 
and  the  gases  of  fermentation.  It  is  impossible  to  conceive  of  chronic 
gastric  dyspepsia  without  intestinal  disturbances  and,  in  fact,  clinically 
the  two  conditions  are  always  associated,  the  latter  as  a  natural  sequence 
of  the  former.  The  symptoms  of  chronic  gastritis  do  not  always  point 
directly  to  the  stomach.  Rhachitis  or  atrophy  in  the  infant,  also  ar- 
rested development,  physical  weakness  and  ana?mia  in  the  older  child, 
may  first  attract  attention.  Usually,  however,  symptoms  of  indigestion 
are  present,  such  as  coated  tongue,  foul  breath,  eructations  of  gas.  pyro- 
sis, nausea,  and  vomiting  after  meals,  or  acid  mucus  vomiting  in  the 
morning.  Colic  in  the  infant  and  gastric  distress  in  older  children  are 
sometimes  relieved  by  eating.  Occasionally  cough  may  cause  a  suspicion 
of  lung  trouble.  Restlessness,  loss  of  sleep,  and  capricious  or  inordinate 
appetite,  may  lead  to  the  diagnosis  of  intestinal  worms.  Constipa- 
tion with  abdominal  distention,  borborygmi  and  flatulence  from  foul- 
smelling  gas,  is  common  in  older  children.  Dilatation  of  the  stomach 
may  occur,  especially  in  rhachitic  children  and  in  infants  who  are  habit- 
ually overfed. 

The  upper  border  of  the  stomach  remaining  fixed,  constant  dragging 
may  cause  gastroptosis,  so  that  the  greater  curvature  may  be  found  far 
to  the  left,  and  extending  below  the  level  of  the  umbilicus.  In  this  sac- 
culated form  the  viscus  cannot  readily  empty  itself  through  the  pylorus. 
The  food  is  long  retained,  undergoing  fermentative  changes  until  re- 
lieved by  emesis.  The  symptoms  of  dilatation,  aside  from  those  of  chronic 
indigestion,  are  an  increased  area  of  tympany  on  percussion— which 


260         DISEASES    OF    THE    GASTROENTERIC    TRACT 

must  be  distinguished  from  distention  of  the  transverse  colon — and  oc- 
casional vomiting  of  a  large  quantity  of  fluid  and  partly-digested  food. 
The  capacity  of  the  stomach  may  be  determined  by  measuring  the  water 
siphoned  out  through  the  tube  after  filling  the  organ. 

Prognosis. — The  prognosis  in  early  infancy  is  bad  on  account  of  the 
tendency  to  marasmus  and,  in  the  summer  months,  to  acute  fatal  enter- 
itis. In  older  children  the  disorder  may  continue  indefinitely  or  may  be 
cut  short  by  fatal  intercurrent  disease,  against  which  these  children 
show  little  resistance.  Judicious  management,  begun  early,  will  do  much 
to  relieve  this  condition  and  a  cure  may  be  expected  in  the  majority 
of  cases. 

Treatment. — An  important  part  of  the  treatment  consists  in  securing 
the  intelligent  co-operation  of  parents  and  nurse,  since  the  regulation  of 
the  diet  as  to  quality,  also  as  to  the  frequency  and  method  of  feeding, 
is  absolutely  essential.  The  stomach  should  be  washed  out  daily  with 
warm  sterile  water,  to  which,  if  much  fermentation  be  present,  sodium 
bicarbonate  or  Seller's  solution  may  be  added.  The  food  for  infants 
should  at  first  be  moderate  in  quantity  and  contain  low  percentages  of 
fat,  proteids  and  carbohydrates.  Regular  intervals  of  from  two  to 
three  hours  must  be  observed.  As  the  stomach  recovers  its  tone  the 
quantity  and  percentages  may  be  gradually  increased.  Occasionally 
gruels  of  dextrinized  cereals  are  better  tolerated  than  the  most  carefully 
modified  milk,  and  may  be  temporarily  substituted.  Older  children 
who  resist  lavage  may  be  compelled  to  drink  daily  copiously  of  warm 
soda  solution,  if  possible,  to  the  production  of  emesis,  not  only  to  re- 
lieve the  stomach  of  food  remnants  but  to  dissolve  and  remove  the 
tenacious  mucus  which  clings  to  its  walls,  interfering  with  the  action  of 
the  digestive  secretions.  The  use  of  the  alkalies  in  these  cases  is  not  so 
much  to  neutralize  the  hyperacidity  as  to  dissolve  the  viscid  mucus  which 
accompanies  the  catarrhal  inflammation. 

The  diet  must  be  restricted  to  plain  and  easily  digested  articles  of 
food.  Condiments,  much  meat,  candies,  and  pastry,  should  be  rigidly 
excluded.  Fruits  should  be  stewed  and  cereals  thoroughly  cooked.  No 
hard  and  fast  rules  for  diet  can  be  laid  down,  but  careful  observation  is 
necessary  that  each  case  be  fed  according  to  its  special  requirements. 

In  infants,  as  well  as  in  children,  the  tincture  of  nux  vomica  is  valu- 
able as  a  stomachic  tonic.  It  stimulates  the  normal  gastric  secretion  and 
improves  peristalsis  by  toning  up  the  muscular  structures.  Full  doses  act 
best  in  the  majority  of  cases ;  two  minims  (0.12  C.c.)  for  each  year  of  age, 
properly  diluted,  may  be  given  four  times  daily,  preferably  before  feed- 
ing. If  the  tongue  remain  coated  and  breath  foul,  dilute  hydrochloric 
acid,  in  similar  doses,  should  be  given  after  food.  Angemic  children  may 
require  iron,  of  which  the  organic  preparations  are  preferable,  although 
the  tincture  of  the  chloride  may  be  substituted  for  the  hydrochloric  acid 
with  good  advantage.  In  marasmic  babies  and  extremely  delicate  chil- 
dren with  weak  hearts,  daily  massage  with  inunctions  of  absorbable  fats 
may  help  out  the  exercise  and  feeding. 


AMOEBIC    DYSENTERY  261 

The  value  of  sunlight,  fresh  air,  and  moderate  exercise  can  not  be 
overestimated,  and  a  change  of  climate  is  frequently  of  great  service. 

AMCEBIC   DYSENTERY. 

A  form  of  colitis  due  to  the  amoeba  eoli,  and  known  as  one  of  the 
varieties  of  tropical  dysentery,  is  only  occasionally  met  with  in  the  north- 
ern portions  of  the  United  States.  Although  many  returned  soldiers 
from  the  Philippines,  since  the  Spanish- American  war,  were  found  to  be 
suffering  from  amoebic  colitis,  but  few  cases  of  this  disease  have  been 
reported  in  children.  With  the  widespread  impetus  to  the  bacterial  ex- 
amination of  the  diarrhceal  dejecta,  given  by  the  Shiga-Flexner  investiga- 
tions, the  paucity  of  reported  findings  of  the  amoeba  coli  would  seem  to 
disprove  the  claim,  recently  made,  for  a  wider  prevalence  of  this  form 
of  colitis  in  children. 

From  the  reported  cases  there  is  apparently  but  little  difference  be- 
tween the  amoebic  colitis  and  that  due  to  other  causes,  with  perhaps  the 
exception  of  a  lower  range  of  temperature  and  a  more  marked  tendency 
to  chronicity  of  the  former  disease.  Like  the  amoebic  dysentery  of 
adults,  the  onset  may  be  acute  and  terminate  fatally  in  two  or  three 
weeks.  Usually,  however,  the  acute  onset  subsides  to  a  subacute  course, 
with  periods  of  remission  and  with  alternating  constipation  and  diar- 
rhoea. The  stools  contain  mucus  and  occasionally  blood.  If  the  child 
survive  the  acute  attack  he  becomes  emaciated  and  weak  and  finally 
dies  from  exhaustion  or  succumbs  to  some  intercurrent  disease.  Occa- 
sionally cases  seemingly  recover,  but  the  usual  course  is  prolonged  and 
obstinate,  with  a  recurrence  of  the  symptoms  after  the  slightest  dietetic 
error. 

A  common  lesion  of  chronic  amoebic  colitis  is  the  formation  of  ulcers 
in  the  colon  and  rectum.  A  characteristic  of  these  ulcers  is  that  they 
undermine  the  mucosa  and  may  burrow  in  the  submucous  tissues ; 
whereas,  the  lesions  of  the  ordinary  ulcerative  colitis  are  shallow  and 
superficially  situated  upon  the  ridges  of  the  mucous  membrane.  In 
children,  abscesses  of  the  liver  and  other  viscera,  common  to  the  amoebic 
colitis  of  adults,  are  seldom  found. 

The  diagnosis  from  other  forms  of  colitis  is  made  from  the  presence 
of  amoebas  in  the  bowel  movements. 

Aside  from  tonics  and  a  diet  of  predigested  foods,  the  special  treat- 
ment of  a  case  of  amoebic  dysentery  consists  in  enemata  of  quinine,  in 
solutions  varying  in  strength  from  1  :  5000  to  1  :  250,  for  the  purpose 
of  destroying  the  amoeba. 

INCONTINENCE   OP   RECES. 

Incontinence  of  faeces  is  a  common  symptom  in  transverse  myelitis 
or  in  paraplegic  conditions  from  injury  to  the  lumbar  spine.  Loss  of 
the  control  of  the  sphincter  is  occasionally  seen  in  adynamic  nervous 
condition  and  is  common  in  the  resultant  prostration  of  acute  or  chronic 
disease,  such  as  typhoid  fever,  pneumonia,  or  tuberculosis.     Obstinate 


262         DISEASES    OF    THE    GASTRO-ENTERIC    TRACT 

constipation  with  fecal  impaction  of  the  rectum,  may  result  in  sphincter 
incompetency  from  overstretching.  In  such  cases  the  tone  is  usually 
recovered  in  a  few  days  after  the  removal  of  the  cause. 

The  treatment  of  this  condition,  aside  from  that  of  the  disease  upon 
which  it  depends,  includes  the  use  of  nux  vomica  or  strychnia,  with  or 
without  belladonna.  Iron  is  indicated  in  the  anaemia,  preferably  the 
tincture  of  the  chloride,  which  may  be  given  well  diluted  in  doses  of 
from  two  to  ten  minims  (0.12-0.6  C.c.)  three  times  a  day.  When  con- 
stipation exists  such  purgatives  as  aloes  may  be  added.  In  certain  neu- 
rotic children  with  atony  of  the  sphincter  ani,  fluid  extract  of  ergot  in 
doses  of  five  to  fifteen  minims  (0.3-0.9  C.c.)  three  times  a  day  may  be 
found  useful. 

CONSTIPATION. 

Many  causes  have  been  assigned  for  the  obstinate  constipation  so 
frequently  encountered  in  infancy  and  childhood.  Certain  anatomical 
and  physiological  conditions  are  contributory.  Among  the  former  are  ( 1 ) 
the  transitional  developmental  state  of  the  intestine,  seen  in  the  movable 
ceecum;  (2)  the  relatively  long  descending  colon,  the  enormous  erratic 
loop  of  the  sigmoid,  and  the  redundant  rectum,  most  of  which  lies  above 
the  pelvic  brim;  (3)  the  loose  mesenteric  attachments  necessary  for 
the  changing  relation  of  future  growth;  (4)  the  immature  state  of 
muscular  structures  and  secreting  glands.  In  addition  to  the  local  in- 
stability of  the  gut,  the  inefficient  musculature  of  the  abdominal  walls 
renders  forced  expulsory  efforts  at  defecation  futile  in  the  infant. 
Among  the  recognized  causes  may  be  mentioned :  first,  diet ;  second,  con- 
ditions which  induce  muscular  atony ;   third,  pain  or  spasm. 

Since  the  onward  movement  of  aliment  and  fasces  through  the  intes- 
tine is  dependent  upon  its  vermicular  action,  it  is  evident  that  any- 
thing which  diminishes  peristalsis  favors  constipation.  The  contents  of 
the  bowel  may  be  such  as  not  to  excite  peristalsis  from  blandness  of  con- 
sistency or  deficiency  in  bulk.  Occasionally  constipation  in  the  nursling 
occurs  from  paucity  of  fat  or  from  excess  of  proteids  in  the  mother's 
milk.  Poor  breast  milk  may  lead  to  constipation  from  deficiency  in  all 
the  solids,  and  hence  paucity  of  residual  matter.  On  the  other  hand, 
excess  of  fat  with  paucity  of  sugar  may  lead  to  constipation  from  indi- 
gestion and  the  resultant  congestion  of  the  mucosa  and  interference  with 
secretions.  Tenacious  mucus,  adherent  to  the  villi,  may  obtund  the  sensi- 
bility of  the  intestinal  wall  to  the  detriment  of  peristaltic  response. 
Babies  fed  on  cow's  milk  are  particularly  prone  to  constipation  for  the 
above  reasons ;  also  children  who  are  fed  boiled  or  even  pasteurized  milk. 
Diminished  intestinal  secretion  due  to  loss  of  fluid  from  diabetes,  from 
excessive  perspiration,  profuse  diarrhoea,  or  insufficient  ingestion  of 
water,  undoubtedly  favors  constipation.  Paucity  of  bile  either  from  in- 
sufficient secretion  or  from  obstruction  to  its  discharge  into  the  duo- 
denum, may  lead  to  torpor  of  the  bowel.  Excess  of  starchy  and  saccha- 
rine foods  which  from  fermentation  causes  distention  of  the  bowels  with 
gas,  inhibits  peristalsis  from  paresis  of  the  muscular  structure.     Pro- 


CONSTIPATION  263 

longed  use,  also,  of  the  coarse  foods  with  bulky  residuum  may  diminish 
the  activity  of  the  bowels. 

"Whatever  be  the  condition  of  the  bowel  contents,  atony  of  the  muscu- 
lar structure  will  diminish  peristalsis  and  result  in  fecal  accumulation. 
This  condition  is  more  apt  to  obtain  in  the  large  intestine,  which  is  prac- 
tically only  a  receptacle.  General  malnutrition  or  myasthenia  after 
acute  diseases  are  frequent  causes  of  muscular  atony  of  the  bowel. 
Overdistention  of  the  gut  from  fecal  accumulation  robs  the  tissues  of 
their  resiliency  and  obtunds  the  reflex  excitability  through  which  peri- 
stalsis is  established,  so  that  constipation  may  be  the  result  of  habit- 
ual neglect  to  evacuate  the  bowels.  This  may  come  about  through  pre- 
occupation, the  child's  unwillingness  to  leave  play,  through  painful  defe- 
cation from  spasm  of  the  sphincter  due  to  anal  fissure  or  hemorrhoids. 

Constrictions  due  to  congenital  malformations,  visceral  displace- 
ments, inflammatory  adhesions,  or  to  neoplasms,  may  cause  obstruction 
of  the  bowels. 

Symptoms. — Though  never  fatal,  per  se,  the  results  of  habitual  con- 
stipation are  interference  writh  various  physiological  functions,  which 
produce  symptoms.  The  coated  tongue,  foul  breath,  muddy  complexion, 
and  concentrated  urine,  are  all  expressions  of  defective  elimination 
by  the  bowel.  Restlessness,  irritability,  anaemia,  and  malnutrition  are 
common  accompaniments.  Gastric  indigestion,  hepatic  torpor,  embar- 
rassed heart  action  and  dull  intellect,  with  oedema  and  coldness  of  the 
extremities,  may  all  be  due  to  stasis  from  venous  congestion  of  the 
splanchnic  area.  Colic  and  tympanitic  distention  of  the  gut  in  consti- 
pation is  common,  while  respiratory  embarrassment  and  disturbed  heart 
action  may  be  increased  to  a  dangerous  degree  by  upward  pressure  of 
the  diaphragm. 

Anal  fissure,  rectal  prolapse,  and  hemorrhoids  result  from  straining 
and  the  passage  of  large  masses  of  hardened  faeces.  Prolonged  pressure 
and  irritation  of  the  mucosa  may  cause  ulcerations.  Appendicitis,  peri- 
typhilitis  and  intussusception  are  among  the  resultant  disorders  of  con- 
stipation. 

The  stools  are  usually  dry,  crumbling,  and  light-colored  from  lack 
of  bile;  or  putty-like,  dark,  tenacious,  and  malodorous.  The  dejection 
may  be  in  round  marble-like  masses  and  coated  with  mucus.  The  reten- 
tion may  be  only  in  the  rectum,  the  faeces  showing  no  evidence  of  indiges- 
tion. The  lowered  vitality  from  diminished  metabolism,  and  the  co- 
proemia  due  to  resorption  of  retained  excreta,  make  constipation  a  pre- 
disposing factor  in  all  diseases  which  prey  upon  impaired  resistance. 
Occasionally  ribbon-like  dejections  may  occur  daily,  or  there  may  be 
intermittent  diarrhoea!  discharges  even  though  large  masses  are  retained 
at  the  flexures  of  the  colon. 

The  diagnosis  of  constipation  is  usually  self-evident,  although  digital 
exploration  of  the  rectum  and  palpation  along  the  colon  will  reveal 
unsuspected  fecal  retention  in  many  cases.  Careful  examination  should 
never  be  neglected  in  children  showing  any  of  the  above  mentioned  symp- 


264         DISEASES    OF    THE    GASTRO-ENTERIC    TRACT 

toms.  Irritation  about  the  anus  or  blood-streaked  stools  should  always 
arouse  suspicion  of  constipation  in  spite  of  the  reported  daily  evacuation 
of  the  bowels. 

Treatment. — The  endless  variety  of  treatment  suggested  but  proves 
the  obstinacy  of  the  disorder.  Probably  no  condition  of  infancy  or 
childhood  is  fraught  with  greater  annoyance  and  in  which  therapy  is  so 
frequently  disappointing.  The  problem  for  its  relief  is  in  the  determina- 
tion of  the  principal  cause.  The  history  of  the  symptoms  and  a  careful 
exploration  of  the  rectum,  will  do  much  to  eliminate  structural  lesions. 
The  character  of  the  faeces  and  analysis  of  the  mother's  milk  may  fur- 
nish clues.  Paucity  of  fat  may  be  corrected  by  the  administration  of  a 
teaspoonful  or  two  of  cream  before  putting  the  child  to  the  breast,  until 
improvement  of  the  mammary  secretion  is  secured  (see  Chapter  on 
Lactation  ).  Dry  stools  call  for  water,  which  should  be  freely  given 
between  feedings.  Occasionally  the  milk  diet  may  be  improved  by  the 
addition  of  farinaceous  gruels,  as  strained  oatmeal.  In  older  children 
who  drink  milk  freely,  well  cooked  starchy  foods  served  with  sugar  and 
cream  may  be  partially  substituted.  Animal  broths  and  meats  may  be 
added  if  the  diet  has  been  too  exclusively  cereal.  The  overingestion  of 
cream  as  a  remedy  for  constipation,  though  a  great  benefit  in  many 
cases,  sometimes  defeats  this  purpose.  Some  infants  improve  by  being 
allowed  to  suck  molasses  taffy,  and  other  children  may  be  given  corn- 
meal  mush  or  brown-bread,  with  free  supply  of  molasses.  Corn  and 
whole- wheat  bread,  with  plenty  of  treacle  and  ripe  fruits,  are  frequently 
useful.  Stewed  prunes  may  be  added  to  the  dietary,  and  washed  figs, 
which  most  children  love,  may  be  allowed.  Chopped  figs,  soaked  over 
night,  in  a  decoction  of  senna,  a  half  ounce  (15  C.c.)  of  the  dry  leaves 
to  a  quart  (1  litre)  of  water,  will  be  eaten  readily  by  the  child  and  may 
be  given  at  bedtime  to  promote  a  morning  evacuation. 

*  Improvement  of  the  general  muscular  tone  by  all  available  agents  is 
a  great  desideratum.  Fresh  air  and  freedom  to  play  are  important. 
Although  usually  regarded  as  contraindicated,  iron  in  some  organic 
preparation  may  be  necessary  for  the  anaemia  and  muscular  atony.  Xux 
vomica  is  valuable  to  promote  peristaltic  vigor,  while  massage  of  the 
abdomen  must  not  be  overlooked. 

For  the  immediate  relief  of  lower  bowel  or  rectal  accumulations, 
soapy  water  enemata  or  gluten  suppositories  should  be  used.  The  in- 
troduction of  a  soap  tent,  previously  dipped  in  warm  water,  may  be  all 
that  is  required  to  empty  the  rectum.  In  obstinate  rectal  torpor,  peris- 
talsis may  be  excited  by  a  small  clyster  of  pure  glycerin,  or  a  glycerin 
suppository  first  dipped  in  warm  water  may  be  introduced. 

The  administration  of  laxatives  by  mouth  should  be  avoided  until 
all  other  means  for  correction  have  failed.  Occasionally  the  accompany- 
ing indigestion  demands  attention:  and  the  heavily  coated  tongue  and 
foul  breath,  indicative  of  repressed  elimination,  may  call  for  small  doses 
of  calomel,  ipecac,  and  soda,  repeated  at  frequent  intervals  for  a  day 
or  two.    Aloes  combined  with  nux  vomica  and  cascara,  in  eligible  form, 


MUCOUS   DISEASE  265 

may  act  as  a  tonic,  corrective,  and  peristaltic  persuader  to  the  entire 
intestinal  tract,  but  should  not  be  Long  continued  or  relied  upon  to  the 
exclusion  of  the  hygiene  and  dietary  measures  above  mentioned.  Castor 
oil  and  rhubarb,  of  such  common  use,  are  contraindicated  as  constipat- 
ing in  their  secondary  effects.  In  insufficient  biliary  secretion,  as  indi- 
cated by  light-colored  stools,  sodium  phosphate,  two  to  four  grains  (0.13- 
0.25  Gm.),  should  be. given  to  a  nursling  with  every  feeding.  In  older 
children,  five  to  ten  grains  (0.3-0.65  Gm.)  may  be  used  on  the  food  in 
place  of  common  salt. 

In  large  fecal  accumulations  evacuant  enemata  should  be  preceded 
by  an  injection  of  olive  oil,  from  a  drachm  to  two  ounces  (4-60  C.c), 
which  is  allowed  to  remain  for  half  an  hour  or  more  to  soften  and 
lubricate  the  fecal  mass.  Sweet  oil  may  also  be  administered  by  the 
mouth  to  good  advantage.  An  eligible  preparation  is  glycerin  one 
ounce  30  Cc),  sweet  oil  two  ounces  (60  C.c),  one  egg,  and  simple  elixir 
one  ounce  (30  C.c).  This  should  be  thoroughly  shaken  in  a  bottle  and 
given  in  teaspoonful  doses  four  times  a  day  to  a  child  of  one  year. 
(To  be  kept  on  ice  or  frequently  renewed.) 

Anal  fissure,  spasm  of  the  sphincter,  and  hemorrhoids  call  for  surgi- 
cal treatment.  Of  chief  importance  in  the  prevention  and  correction  of 
constipation  is  the  establishment  of  the  habit  of  regular  defecation.  Too 
much  emphasis  cannot  be  laid  upon  this  hygienic  measure  which,  if  ob- 
served, would  render  constipation  in  children  as  rare  as  it  is  now  com- 
mon. At  a  certain  time  each  day,  preferably  after  breakfast,  the  child 
should  be  placed  upon  a  stool  in  such  a  position  that  the  abdominal 
muscles  may  best  act  to  reinforce  the  expulsive  efforts  of  the  bowel.  For 
children  the  ordinary  seat  in  the  closet  is  too  high,  so  that  a  footstool 
should  be  supplied  of  sufficient  height  to  give  a  firm  support.  The 
mother  or  nurse  may  well  afford  the  time  to  supervise  the  child's  morning 
defecation  until  regularity  of  habit  is  insured. 

MUCOUS    DISEASE CHRONIC    INTESTINAL    CATARRH;     GASTRO-DUODENAL    CA- 
TARRH;    CHRONIC    MUCOCOLITIS;     INTESTINAL    INDIGESTION;     TUBULAR 
DIARRH03A;     MYXONEUROSIS    COLI ;     COLICA    MUCOSA. 

Under  the  above  and  other  names  has  been  described  a  condition 
that  is  not  uncommon  in  children  between  the  sixth  and  twelfth  years, 
and  is  occasionally  seen  in  younger  children  and  infants.  Although  not 
generally  classed  among  the  inflammations,  the  condition  may  be  pre- 
ceded or  accompanied  by  lesions  of  the  gastro-intestinal  mucosa,  varying 
from  mere  areas  of  hyperemia  to  extensive  structural  changes,  such  as 
ulcerations,  dilatations,  and  ptosis.  Typical  mucous  disease,  however, 
shows  no  lesion  of  the  intestinal  mucosa,  the  mucus  found  clinging 
tenaciously  to  the  lining  membrane  of  the  colon,  differing  from  normal 
mucus  only  in  quantity  and  density,  the  latter  from  its  loss  of  water  by 
absorption. 

Three  sets  of  manifestations  contend  for  priority  in  this  disorder,  to 
each  of  which  prime  etiologic  importance  has  been  ascribed  by  different 


266        DISEASES    OF    THE    GASTROENTERIC    TRACT 

observers.  First,  the  functional  digestive  disturbance;  second,  the 
structural  alterations  in  the  digestive  viscera;  third,  the  nervous  and 
constitutional  condition  of  the  child.  A  predisposition  is  seen  in  feeble 
and  high-strung  children  of  neurotic  parentage  and  in  those  debilitated 
from  previous  disease,  especially  from  pertussis  and  attacks  of  acute 
indigestion. 

Symptoms. — The  child  is  usually  listless,  easily  fatigued,  or  irritable, 
and  shows  emaciation,  with  muddy  or  icteroid  color  of  the  skin.  This  is 
dry,  harsh,  and  may  be  scaly.  The  hair  is  dry,  the  eyes  dull,  with  dark 
circles,  the  tongue  is  swollen  and  coated  or  shows  irregular  glazed  patches, 
and  the  tonsils  are  hypertrophied  with  more  or  less  follicular  pharyngitis. 
The  breath  has  a  peculiarly  offensive  odor ;  the  prolabia  are  frequently 
pallid  as  in  nausea.  Circumscribed  areas  of  flushing  may  appear  on  the 
cheek.  A  short,  dry  cough,  without  pulmonary  lesions,  is  common. 
There  is  disturbed  sleep,  grinding  of  teeth,  and  night  terrors.  The 
appetite  is  capricious,  frequently  insatiable,  with  periods  of  anorexia. 
The  wasting  of  the  tissues  is  marked  in  spite  of  the  large  amount  of  food 
ingested.  This,  with  the  cough  and  the  loss  of  strength,  may  lead  to  the 
apprehension  of  tuberculosis. 

The  second  set  of  symptoms  is  associated  with  functional  digestive 
disturbances.  The  abdomen  is  distended  and  is  in  marked  contrast  to 
the  general  emaciation.  It  may,  at  times,  show  tenderness  on  pressure. 
Borborygmi,  and  the  escape  of  flatus  by  mouth  or  rectum,  are  common. 
Constipation  is  the  rule,  alternating  with  attacks  of  diarrhoea,  during 
which  the  discharges  are  sometimes  very  offensive,  showing  undigested 
and  putrefying  food  and  large  quantities  of  mucus.  The  mucus,  as  it 
comes  away,  may  assume  odd  forms,  resembling  a  ribbon  or  tapeworm. 
Occasionally  membrane-like  casts  of  the  gut  are  discharged  entire,  but 
rarely  is  a  true  membrane,  blood,  or  pus  seen  in  these  stools. 

The  third  set  of  conditions  is  seen  in  the  dilatation  of  the  stomach 
and  colon,  particularly  the  transverse  portion.  The  lower  border  of 
the  transverse  colon  may  sag  far  below  the  level  of  the  umbilicus.  There 
may  be  enormous  dilatation  of  the  sigmoid  flexure.  Fissures  of  the  anus 
may  occur,  with  rectal  prolapse  and  stasis  in  the  lower  hemorrhoidal 
veins. 

Etiology. — Many  observers  have  claimed  that  the  affection  is  a  neuro- 
sis, and  cite  the  nervous  disturbances  and  constitutional  condition  in 
confirmation.  Others  attribute  to  the  enteroptosis  a  mechanical  cause 
for  the  constipation  and  excessive  secretion  with  its  periodic  discharge. 
A  more  rational  etiology  appears  to  be  along  the  line  of  chronic  gastro- 
intestinal indigestion,  originally  from  predisposition,  but  accentuated 
by  dietetic  errors  due  to  caprice  and  malhygiene.  The  practice,  among 
the  poorer  classes,  of  sharing  with  the  children  the  varied  diet  of  their 
elders ;  and  among  the  pampered  children  of  the  well-to-do  the  injudi- 
cious eating  of  sweetmeats,  rich  food,  and  pastries,  is  so  commonly  asso- 
ciated with  mucous  disease  as  to  suggest  causal  relations. 

Theoretically,  if  not  practically,  chronic  gastric  indigestion  and  duo- 


MUCOUS    DISEASE  267 

denal  catarrh,  with  resulting  coprsemia,  serve  as  a  partial  explanation 
for  many  of  the  symptoms.  Whether  the  cnteroptosis  be  due  to  dilata- 
tion from  accumulations  of  gases  and  aliment,  or  from  anomalous  de- 
tachment of  the  tenth  rib,  is  immaterial,  the  atony  of  the  muscular  struc- 
tures of  the  prima  via  but  shares  the  general  atonic  conditio]]  of  the 
muscular  system. 

The  disease  is  essentially  chronic,  the  above  symptoms  being  varied 
by  acute  exacerbations  of  anorexia,  occasional  vomiting,  colicky  pains, 
with  some  rise  in  temperature,  and  general  malaise,  followed  within  a 
few  hours  by  diarrhoea  which  may  continue  for  several  days,  causing  con- 
siderable depression.  After  the  attack,  which  usually  terminates  in  a 
profuse  discharge  of  mucus,  the  habitual  constipation  returns  with  an 
obstinacy  which  leads  to  the  frequent  use  of  laxatives. 

Diagnosis. — The  diagnosis  from  general  tuberculosis,  or  from  pul- 
monary tuberculosis  with  intestinal  complications,  is  rendered  probable 
by  the  usually  normal  or  subnormal  temperature  and  the  absence  of  pul- 
monary and  other  physical  signs  of  that  disease.  It  must  be  remembered, 
however,  that  the  debility  incident  to  mucous  disease  favors  the  develop- 
ment of  tuberculosis  or  any  infection  to  which  the  child  may  be  exposed. 

Occasionally  the  ribbons  and  shreds  in  the  stools  are  mistaken  for 
tapeworm  or  ascarides,  which  error  the  nervous  and  digestive  symptoms 
would  appear  to  confirm.  Examination  of  the  stools  with  a  lens  will 
determine  the  presence  of  worms  or  their  ova.  Parasites  frequently 
accompany  this  mucoid  disease  of  the  intestines. 

The  prognosis  is  hopeful,  under  strict  dietetic  and  hygienic  manage- 
ment, although  the  disease  is  essentially  chronic  and  runs  an  extremely 
tedious  course.  It  may  continue  for  years  with  exacerbations  under 
varying  influences  which  affect  the  neurotic  child. 

Treatment. — The  treatment  consists  in  careful  regulation  of  the  daily 
life  and  supervision  of  the  child's  diet.  All  that  makes  for  develop- 
ment, conservation  of  physical  vigor  and  repression  of  sentimental, 
neurotic  and  morbid  tendencies,  must  be  encouraged.  The  child  must 
be  relieved  of  arduous  school  duties  for  which  the  stimulation  of 
healthful  outdoor  occupation  and  pastimes  must  be  substituted.  The 
daily  cold  bath  and  oil  massage  will  help  to  improve  the  general  atony. 
The  bowels  must  be  taught  to  move  regularly  by  a  diet  containing  a  large 
amount  of  residual  matter.  In  this  way  the  intestines  are  filled  with  a 
softened  mass  which  takes  up  the  mucus  and  promotes  peristalsis.  Young 
children  may  take  unstrained  oatmeal  porridges  made  from  unbolted 
cereals,  with  plenty  of  rich,  fresh  cream,  or  even  well  cooked  wheat- 
bran  mush,  ground  popcorn,  graham,  whole  wheat,  or  corn  bread,  with  a 
liberal  supply  of  butter,  and  baked  potato  with  gravy.  A  free  supply 
of  salt,  cream,  sugar  of  milk,  and  butter  may  be  given,  but  cane-sugar, 
milk,  finely-ground  cereals  and  meats  should  be  interdicted.  Older  chil- 
dren may  take,  in  addition  to  the  above,  almost  all  kinds  of  fresh 
vegetables  and  fruits,  such  as  currants,  cranberries,  gooseberries,  grapes, 
figs,  prunes,  etc.    Additional  fat  may  be  given  in  the  form  of  olive  oil 


268        DISEASES    OF    THE    CASTRO-ENTERIC    TRACT 

with  salads.  Pastry,  confections,  and  fine  starch  or  flour  puddings  should 
be  carefully  excluded,  and  cocoa  should  be  substituted  for  milk.  A 
moderate  amount  of  meat,  especially  fat  bacon,  is  allowable.  Saline 
waters,  such  as  Kissingen,  should  be  used  freely. 

It  is  impossible  to  more  than  suggest  an  outline  of  diet.  The  prin- 
ciples to  be  kept  in  mind  are  the  use  of  food  having  a  bulky  residuum, 
the  liberal  supply  of  fats,  the  generous  use  of  salt  and  saline  waters, 
the  avoidance  of  cane-sugar  and  concentrated  carbohydrates,  and  the 
discontinuance  of  routine  purgative  medication.  The  details  of  treat- 
ment must  be  adapted  to  the  peculiarities  of  the  individual  case. 

An  occasional  enema  of  normal  salt  solution  may  be  given  when  it 
does  not  induce  painful  spasm  of  the  bowel.  High  enemata  of  sweet 
oil,  four  to  ten  ounces,  are  preferable,  and  in  the  beginning  may  be 
repeated  daily.  With  a  well  filled  colon,  judicious  abdominal  mas- 
sage may  accomplish  much  in  promoting  peristalsis.  Obstipation  from 
painful  spasm  of  the  gut  calls  for  hot  abdominal  applications.  Anodynes, 
as  small  doses  of  opium  and  belladonna  will  relieve  the  spasm  and  fre- 
quently promote  evacuation  of  the  bowel  contents. 

Changes  either  to  or  from  the  above  mentioned  diet  should  be  made 
gradually.  Bearing  in  mind  the  underlying  neurotic  diathesis  and  the 
recurrent  character  of  the  intestinal  disturbance,  the  child  should  never 
be  pronounced  cured  of  mucous  disease  until  many  months  after  the 
disappearance  of  an  excess  of  mucus  from  the  stools,  and  substantial 
gain  is  evident  in  weight  and  general  vigor. 

INTESTINAL   PARASITES — WORMS. 

Parasites  are  sometimes  found  in  the  intestinal  tract  in  great  num- 
bers and  considerable  variety,  and  were  formerly  considered  responsible 
for  most  of  the  ills  of  childhood.  As  the  true  nature  of  various  diseases 
became  better  understood,  intestinal  worms  were  gradually  relegated  to 
the  background,  until  recently  medical  writers  of  distinction  have  gone 
so  far  as  to  claim  that  worms  in  the  digestive  tract  were  productive  of 
no  disorder,  nor,  indeed,  of  any  symptoms  that  might  indicate  their 
presence.  To  substantiate  this  assertion,  numerous  post-mortem  discov- 
eries of  worms  are  cited  in  patients  dead  from  accidental  causes  who 
have  exhibited  in  life  no  evidence  of  these  parasites.  Frequently  the 
first  intimation  of  intestinal  parasites  is  their  presence  in  the  stools 
or  vomitus  of  individuals  enjoying  good  health. 

On  the  other  hand,  however,  it  is  a  matter  of  too  common  observation 
that  the  expulsion  of  intestinal  worms  has  resulted  in  the  relief  of  symp- 
toms of  grave  disorders  which  could  be  attributed  to  no  other  cause. 
The  too  common  custom  among  physicians  of  making  light  of  the  etiologic 
importance  of  intestinal  worms  simply  because  of  their  undue  prominence 
in  the  lay  mind,  is  neither  judicious  nor  scientific.  Tapeworms  do  rob 
the  host  of  an  appreciable  amount  of  aliment  which,  in  some  instances  of 
achylia  or  enfeebled  digestion  from  any  cause,  may  be  a  determining  fac- 
tor in  malnutrition  and  lowered  resistance  to  incidental  infection.     The 


INTESTINAL    WORMS  269 

Uncinaria  Americana,  and  probably  other  forms  of  the  anchylostomata, 
cause  by  their  presence  in  the  small  intestine  symptoms  analogous  to 
those  of  pernicious  anaemia,  with  as  surely  fatal  results,  if  not  relieved 
by  expulsion  of  the  parasite.  Lesions  and  morbid  processes  in  the  intes- 
tinal tract  and  adjacent  structures  are  too  frequently  associated  with 
the  common  nematode  guests  to  hold  these  parasites  altogether  blameless ; 
while  the  known  accidents  due  to  the  invasion,  by  the  round-worm,  of 
sinuses,  tubes,  and  ducts,  are  sufficiently  common  to  make  their  presence 
in  the  prima  via  a  menace  to  the  health,  if  not  the  life  of  the  host. 

Reflex  disturbances,  especially  in  the  highly  sensitive  organisms  of 
children,  from  energetic  intestinal  parasites,  may  present  such  a  variety 
of  phenomena  that  their  mere  enumeration  would  be  tedious.  The  scep- 
tic who  questions  the  relationship  of  cause  and  effect  in  these  cases 
must  be  satisfied  with  the  same  explanation  which  serves  in  the  solution 
of  other  pathological  problems, — i.e.  the  cessation  of  the  symptoms  upon 
the  removal  of  the  cause,  namely,  the  worm.  No  one  disputes  the  evil 
effects  of  the  oxyuris  vermicularis  both  through  direct  irritation  and 
reflex  disturbances. 

The  evidence  of  haematologists  concerning  the  findings  in  the  pres- 
ence of  intestinal  parasites  cannot  be  ignored.  Bothriocephalic  anaemia 
is  an  entity  which  calls  for  anthelmintic  therapy  with  an  assurance  of 
success,  regardless  of  the  mooted  point  as  to  whether  the  parasitic  disturb- 
ance be  due  entirely  to  the  abstraction  of  blood  or  in  part  to  a  toxaemia 
in  the  host  from  a  normal  or  pathological  secretion  of  the  worm.  It  has 
been  shown  that  eosinophilia  in  varying  degree  accompanies  intestinal 
parasites  of  whatever  form  or  variety.  This  fact  alone,  although  its  full 
significance  may  not  at  present  be  fully  explained,  is  sufficient  to  refute 
the  claim  that  helminthiasis  is  productive  of  nothing  but  worms. 

The  most  common  intestinal  parasites  found  in  children  are  the 
oxyuris  vermicularis  (thread-,  pin-,  or  seatworm),  ascaris  lumbricoides 
(round-worm),  taenia  mediocanellata  (beef  tapeworm),  the  taenia  solium 
(pork  tapeworm),  and  rarely  the  taenia  elliptica. 

The  oxyuris  vermicularis  (pin- worm)  is  seen  in  the  dejections  or 
about  the  anus  and  genitals  of  children,  and  looks  like  a  white  thread 
from  one-half  to  one  centimetre  in  length,  the  female  being  about  twice 
as  long  as  the  male. 

The  ova  enter  the  child's  body  with  the  food  or  drink,  usually  by 
means  of  polluted  water,  unclean  hands,  or  through  the  agency  of  flies 
and  dust.  The  enveloping  membrane  is  dissolved  in  the  stomach,  releas- 
ing the  embryo,  which  develops  rapidly  in  the  small  intestine,  arriving 
at  full  maturity  in  the  caecum  and  appendix.  Here  fecundation  occurs 
and  the  parasite,  charged  with  ripening  ovules,  finds  its  way  to  the  sig- 
moid and  rectum,  its  favorite  habitat.  The  eggs  are  deposited  in  this 
locality  in  enormous  numbers  and  are  extruded  with  the  dejections  to 
enter  the  body  of  another  host.  Through  lack  of  cleanliness  the  child 
may  reinfect  himself  with  the  ova  of  his  own  parasites. 

The  symptoms  are  principally  due  to  the  pruritus  ani  and  the  irrita- 


270        DISEASES    OF    THE    GASTRO-EXTEPJC    TRACT 

tion  of  the  genitals  from  the  active  motility  and  migratory  habits  of 
these  thread-worms.  This  is  particularly  noticeable  at  night,  causing 
restlessness  and  disturbed  sleep,  and  often  leads  to  masturbation. 

The  diagnosis  is  made  from  the  symptoms.  Oxyuris  vermicularis 
should  always  be  suspected  from  the  symptoms  above  mentioned.  By 
parting  the  nates,  the  worms  are  often  seen  in  the  anal  region.  Micro- 
scopic examination  of  the  fasces  will  reveal  the  eggs,  which  are  unsym- 
metrically  ovoid  in  shape  and  about  one  five-hundredth  of  an  inch  (0.05 
Mm.)  in  length. 

Treatment. — These  parasites  may  be  destroyed  by  copious  enemata  of 
salt  solution,  three  to  four  drachms  to  the  quart  (15  C.c.-l  litre;  of  steril- 
ized water,  every  second  night  until  the  worms  disappear.  A  most  efficient 
remedy  used  in  the  same  way  is  infusion  of  quassia,  one  ounce  to  the  pint 
(30  C.C.-3/2  litre).  The  pruritus  may  be  treated  with  equal  parts  of 
unguentum  hydrargyri  and  vaseline,  applied  nightly.  Since  these  para- 
sites infest  the  bowel  as  far  up  as  the  duodenum,  each  enema  will  destroy 
only  a  limited  number  and  may  have  to  be  repeated  many  times  to  rid 
the  gut  of  their  presence.  It  is  often  advisable  to  administer  an  anthel- 
mintic by  mouth  in  conjunction  with  the  local  treatment.  The  best  agent 
for  this  purpose  is  santonin,  to  which  calomel  is  added  to  secure  prompt 
elimination  and  prevent  toxic  effects  of  the  former  drug,  to  which  young 
children  are  especially  susceptible.  To  a  child  of  two  years,  one-fourth 
of  a  grain  (0.016  Gm.j  of  each,  with  a  little  sugar  of  milk,  may  be 
given  three  times  a  day  for  six  doses.  To  secure  prompt  effect  the  medi- 
cine is  best  given  on  an  empty  stomach,  preferably  after  a  free  purga- 
tion with  castor  oil.  Yellow  urine  and  transient  xanthopsia  follow  the 
administration  of  santonin.  Giddiness  and  tremors  are  indicative  of  the 
toxic  action  of  the  drug  and  their  occurrence  suggests  its  withdrawal 
or  diminution. 

The  ascaris  lumbricoides  (round-worm)  resembles  somewhat  the  com- 
mon earth-worm.  It  is  from  five  to  fifteen  inches  (12-37  Cm.)  long,  one- 
eight  to  one-fourth  (0.31-0.63  Cm.)  of  an  inch  thick,  tapering  gradually 
to  pointed  ends.  It  is  yellowish-pink  when  first  passed,  changing  to  a 
light  brown  upon  exposure,  and  is  marked  by  fine  transverse  rings.  The 
male  is  readily  recognized  by  his  smaller  size  and  incurved  tail.  The 
female  shows  a  genital  orifice  at  the  anterior  third  of  the  ventral  surface 
from  which  the  fecundated  ova  are  extruded  in  enormous  quantities. 
The  eggs  are  oval,  about  one  five-hundredth  of  an  inch  (0.05  Mm.)  long 
and  have  a  thick,  tough  shell  with  a  brownish  nodular  surface.  The 
vitality  of  the  eggs  is  great,  as  they  may  remain  in  water  or  damp 
earth  for  years  in  a  dormant  or  slowly  developing  state.  Probably  an 
intermediate  host  furnishes  the  developing  medium  for  the  embryo, 
although  recent  experiments  show  that  a  few  weeks  of  exposure  to  light 
and  air  ripens  the  ovum  so  that  when  ingested  by  the  child  the  gastric 
juices  dissolve  the  envelope  and  liberate  the  embryo.  A  free  embryo, 
develops  into  a  mature  egg-producins:  worm  in  about  three  months. 
Probably  the  common  source  of  trematode  ova  is  drinking  water  which 


TAPEWORM  271 

has  been  polluted  by  surface  drainage  or  sewage.  Raw  fruits,  vegetables, 
and  salad  greens  no  doubt  furnish  means  of  transmission  to  the  human 
mouth.  Ascarid.es  may  exist  singly  or  by  thousands,  although  rarely  are 
many  found  in  one  host.  Their  usual  habitat  is  the  upper  portion  of 
the  small  intestine,  but  their  migrating  propensities  lead  them  into  the 
stomach,  lower  bowel,  vermiform  appendix,  common  hepatic  duct,  vagina, 
bladder,  oesophagus,  larynx,  Eustachian  tube,  etc.  In  these  situations 
they  give  rise  to  symptoms  peculiar  to  the  structure  and  function  of 
the  invaded  area.  Perforation  of  the  bowel  and  stomach  by  lumbricoids 
has  occurred,  probably  through  ulcerations  from  a  previous  disease. 

They  are  occasionally  vomited  during  pyrexia  from  any  cause,  but 
most  frequently  they  leave  the  body  by  way  of  the  rectum,  dislodged  by 
the  excessive  peristalsis  of  catharsis. 

A  positive  diagnosis  can  be  made  only  by  the  presence  of  the  para- 
site or  its  ova.  Most  of  the  symptoms  attributed  to  the  round-worm  are 
common  to  dyspepsia  and  chronic  enteric  catarrh,  hence  the  professional 
scepticism. 

The  question  of  cause  and  effect  in  the  relationship  between  intes- 
tinal v/orms  and  excessive  intestinal  mucus  has  been  much  discussed. 
Certain  it  is  that  the  two  conditions  are  frequently  associated.  Mal- 
nutrition, indigestion,  and  marasmus,  with  all  their  dependent  conditions 
and  symptoms,  not  to  mention  the  host  of  reflex  disturbances  from  gastro- 
intestinal irritation,  have  been  occasionally  relieved  by  the  expulsion  of 
intestinal  parasites. 

Treatment. — Of  the  anthelmintic  drugs  in  common  use  one  has  proved 
so  efficient  and  safe  that  it  is  justly  regarded  as  a  specific.  Santonin, 
after  a  limited  non-saccharine  diet  for  two  or  three  days  and  after 
the  bowels  have  been  cleared  by  a  purgative,  should  be  given  as  directed 
in  the  treatment  for  pin-worms.  After  an  interval  of  a  fortnight  the 
series  of  six  doses  may  be  repeated  with  similar  preparation. 

Tcenice  (tapeworms)  are  much  more  frequently  encountered  in  chil- 
dren than  many  authors  are  willing  to  admit.  They  are  occasionally 
found  in  young  infants,  especially  bottle-fed  babies,  and  have  been  re- 
ported in  the  newly  born.  The  growing  practice  of  feeding  raw  beef 
juice  to  babies  and  chopped  or  pulped  beef  to  children  easily  explains 
the  advent  of  the  mediocanellata,  while  ground  meat  and  raw  or  im- 
perfectly cooked  sausage  containing  pork  are  so  frequently  eaten  by 
children  that  invasion  by  the  solium  is  understood. 

Other  forms  of  tapeworm  are  found  in  children.  One.  the  taenia 
elliptica,  has  for  its  intermediate  host  the  louse  or  flea  frequently  found 
on  domestic  pets. 

Taeniae  continue  to  grow  by  adding  new  segments  to  their  length  as 
long  as  the  head  retains  its  hold  by  suckers  or  hooklets  upon  the  mucosa 
■ — usually  of  the  upper  part  of  the  small  intestine — so  that  as  intestinal 
peristalsis  of  the  host  sweeps  the  free  end  downward  the  parasite  may 
attain  the  full  length  of  the  intestinal  tract.  Although  usually  solitary, 
two  or  more  tasniae  may  occupy  the  same  gut,  and  as  they  grow  to  their 


272        DISEASES    OF    THE    GASTROENTERIC    TRACT 

full  length  in  from  six  to  twelve  weeks  the  detached  segments  are  con- 
stantly escaping  from  the  anus  and  may  be  found  in  the  clothing  or 
stools.  Their  recognition  is  easy,  although  in  mucoid  stools,  odd  ribbon- 
like forms  suggestive  of  cestodes  are  often  seen.  Free  purgation  often 
brings  away  several  links  or  large  masses  of  the  worm,  but  as  long  as 
the  head  remains  unexpelled  the  parasite  may  live  to  share  his  host's 
pabulum  for  ten  or  twenty  years. 

The  symptoms  of  taenia  are  those  of  malnutrition  and  anaemia,  accom- 
panied by  voracious  or  capricious  appetite,  abdominal  pain,  muscular 
cramps,  and  digestive  disturbances.  The  diagnosis  requires  segments  or 
ova  from  the  rectum  of  the  host.  The  blood  findings  are  interesting,  and 
all  cases  of  progressive  anaemia  should  suggest  the  possibility  of  worms. 
The  microscope  will  show  the  ovum  in  the  dejections. 

Treatment. — The  most  efficient  taeniacides  are  male  fern  and  pome- 
granate root.  Oleoresina  aspidii,  dose  ten  minims  (0.6  C.c.)  for  a  child 
of  five  years,  may  be  given  in  milk  or  in  capsules  every  hour  for  four 
doses.  PeDetierine  tannate,  dose  one-half  grain  (0.032  Gm.)  for  a  child 
of  five  years,  may  be  given  in  simple  elixir  or  milk.  The  administration 
of  the  anthelmintic  should  be  preceded  by  low  liquid  diet  or  an  absolute 
fast  for  twenty-four  hours  and  a  morning  saline  purge.'  After  the 
bowels  have  moved  freely  one  dose  of  the  pelletierine  should  be  given, 
or  four  doses  of  male  fern,  at  intervals  of  forty  to  sixty  minutes,  the 
child  being  kept  in  the  recumbent  position.  Four  hours  later  a  full 
dose  of  castor  oil  should  be  given  to  carry  off  the  worm.  This  seem- 
ingly simple  treatment,  to  insure  success,  must  be  supervised  by  the 
plrysician  in  person  or  by  a  thoroughly  instructed  nurse,  for  unless  the 
head  of  the  parasite  is  secured  the  worm  will  renew  its  growth  in  from 
six  to  twelve  weeks.  The  movement  must  be  washed  on  a  fine  sieve  and 
the  head  sought  for.  In  case  of  its  non-appearance  copious  colonic  flush- 
ing with  normal  salt  solution  may  secure  it. 

The  prophylaxis  against  worms  in  general  is  cleanliness  and  avoid- 
ance of  raw  meats,  raw  vegetables,  and  unsterilized  water. 

INTUSSUSCEPTION. 

Intussusception,  or  invagination  of  the  bowel,  is  frequent  in  early  life. 
About  fifty  per  cent,  of  all  cases  are  reported  as  occurring  in  children 
under  ten  years  of  age,  of  which  number  the  first  year  claims  more  than 
half.  Its  frequency  in  infancy  is  explained  by  the  susceptibility  of  the 
gut  to  peristaltic  disturbances,  the  prevalence  of  diarrhoeal  conditions, 
greater  amplitude  of  its  mesentery,  and  the  mobility  of  the  caecum. 
With  rare  exceptions  the  invagination  proceeds  from  above  downwards, 
the  lower  portion  of  the  gut  turning  in  as  it  is  dragged  onwards  by  the 
advancing  apex  (Fig.  137).  Intussusception  may  occur  at  any  portion  of 
the  intestinal  tract,  although  probably  less  than  one-third  begin  in  the 
small  intestine.  The  commonest  starting-point  is  at  the  ileocaecal  junc- 
tion, whence  the  small  bowel  may  be  swallowed  by  the  large  one  or,  as 
more  frequently  happens,  the  colon  swallows  itself,  advancing  the  ileocae- 


INTUSSUSCEPTION 


273 


cal  valve  as  the  apex  of  the  invagination  until,  in  rare  cases,  it  may 
reach  the  rectum  or  even  protrude  from  the  anus.  Occasionally  the 
vaginating  reduplicates,  so  that  instead  of  three,  five  or  even  seven  thick- 
nesses of  the  intestine  have  been  found  between  the  periphery  of  the  mass 
and  the  lumen. 

The  result  of  extensive  invagination  is  constriction  of  the  vessels  of 
the  gut  and  mesentery,  which  is  dragged  in,  causing  congestion,  swelling, 
inflammation,  adhesion,  necrosis,  and  slough- 
ing of  the  incarcerated  portion.  The  degree 
of  obstruction  depends  upon  the  extent  of 
the  lesion  and  the  amount  of  swelling  and 
constriction,  though  the  passage  is  usually 
blocked. 

The  exciting  cause  of  intussusception  is 
often  obscure,  although  enterocolitis,  ulcera- 
tion of  the  bowel,  appendicitis,  Meckel's  di- 
verticulum, chronic  indigestion,  constipation, 
colic,  typhoid  fever,  pertussis,  intestinal 
worms,  injuries  to  the  abdomen,  and  expo- 
sure to  cold  have  all  been  noted  as  precedent 
or  associated  conditions. 

The  most  prominent  symptoms  are  pain 
in  the  umbilical  region,  and  vomiting,  spas- 
modic in  character,  which,  if  long  continued, 
may  in  older  children  become  fecal.  The 
onset  is  usually  sudden,  the  infant  arousing 
from  sleep  with  a  sharp  cry.  The  stools  be- 
come scanty  and  frequently  cease  altogether, 
although  by  the  second  day  usually  bloody 
mucus  is  passed.  Some  cases  begin  with  a 
mild  diarrhoea  and  suddenly  develop  the 
pain,  vomiting,  and  bloody  stools.  The  temperature  may  be  normal  or 
subnormal  and  symptoms  of  prostration  and  collapse  rapidly  develop. 
A  chronic  form  is  encountered  in  which  symptoms  of  obstruction  are 
wanting,  the  real  condition  being  unsuspected  until  an  abdominal  tumor 
is  discovered.  Tumor  is  present  early  in  a  large  majority  of  cases  and 
may  be  located  anywhere  in  the  abdomen,  but  as  the  disease  progresses 
it  is  rarely  absent  from  the  left  side  and  is  frequently  located  in  the 
rectum  or  sigmoid. 

The  picture  of  acute  intussusception  in  the  infant  is  characterized 
by  the  absence  of  fever  and  cerebral  symptoms,  the  paroxysms  of  pain 
and  vomiting,  the  anxious  facies,  pinched  and  pallid  features,  perspira- 
tion, symptoms  of  collapse  and,  later,  apathy,  coma,  or  convulsions. 
After  the  second  day  there  may  be  fever  from  local  peritonitis  or  infec- 
tion. Cessation  of  pain  after  the  third  day  in  severe  cases  usually  means 
gangrene.  The  duration  varies  from  two  to  seven  days.  In  seventy-five 
per  cent,  of  the  fatal  cases  death  occurs  on  the  fourth  day. 

18 


Fig.  137. — Intussusception. 


274        DISEASES    OF    THE    GASTROENTERIC    TRACT 

The  diagnosis  is  made  from  the  severe  paroxysmal  pain,  vomiting, 
discharge  of  bloody  mucus  in  the  absence  of  fseces,  and  principally  by 
the  presence  of  tumor.  In  examination  for  tumor  the  rectum  should  be 
explored  under  anaesthesia. 

Prognosis. — Neglected  intussusception  is  usually  fatal,  although  a 
few  cases  of  spontaneous  reduction  have  been  reported.  Occasionally, 
after  a  portion  of  the  bowel  has  sloughed  away,  adhesions  preserve  the 
continuity  of  the  tube,  although  in  children  such  recoveries  are  usually 
followed  by  death  in  a  few  months  from  sequelae.  If  diagnosed  early, 
the  probabilities  of  relief  by  intelligent  treatment  are  fair;  yet  recur- 
rences after  reduction  are  not  uncommon  at  any  time  from  twelve  hours 
to  six  weeks. 

Treatment.— 'Early  laparotomy  is  the  rational  treatment.  As  each 
hour's  delay  increases  the  gravity  of  prognosis  in  a  geometric  ratio,  no 
time  should  be  lost  in  measures  which  only  occasionally  have  proved 
successful.  While  waiting  for  the  surgeon  and  during  the  anaesthesia  for 
examination,  distention  of  the  bowel  by  warm  salt  solution  may  be 
tried,  care  being  observed  not  to  use  too  much  force.  The  child  should 
be  inverted  and  the  warm  solution  introduced  through  a  catheter  from 
the  fountain,  which  must  not  be  elevated  more  than  three  feet.  Mean- 
while gentle  massage  of  the  abdomen  should  be  performed  to  promote 
the  filling  and  reduction  of  the  gut.  All  food  must  be  withheld  and 
morphine  should  be  given  hypodermically  to  arrest  the  pain  and  peris- 
talsis. 

VOLVULUS. 

Sudden  obstruction  may  occur  from  a  twist  or  kink  in  the  gut.  If 
the  lesion  be  high  in  the  bowel,  vomiting  will  be  an  early  symptom  upon 
which,  with  the  pain  and  obstipation,  the  diagnosis  depends.  From  in- 
tussusception it  is  differentiated  by  absence  of  bloody  mucus  discharge 
and  of  tumor.  The  only  treatment  is  abdominal  section  to  straighten  the 
kink,  which  should  be  done  promptly. 

APPENDICITIS. 

Appendicitis  is  occasionally  found  in  infants  a  few  months  old,  but 
the  diagnosis  is  rare  before  the  third  year.  Records  from  a  large  num- 
ber of  cases  show  something  more  than  ten  per  cent,  in  the  first  decade 
of  life.  It  is  probable,  however,  that  many  mild  attacks  of  appendicitis 
are  overlooked  in  infancy  or  are  diagnosed  as  acute  intestinal  colic. 

The  etiology  of  inflammation  of  the  appendix  is  obscure.  The  theory 
that  as  age  advances  there  are  progressive  changes  resulting  in  over- 
growth of  the  connective  tissue,  and  predisposing  to  congestion,  may 
help  to  explain  the  greater  frequency  of  appendicitis  in  older  patients. 

In  children,  as  in  adults,  reports  of  this  disease  show  a  large  pre- 
ponderance in  males.  An  explanation  of  the  relative  infrequency  of 
appendicitis  in  girls  has  been  offered  in  the  fact  of  the  frequent  exist- 
ence of  the  appendico-ovarian  ligament  which  carries  an  additional  blood 


APPENDICITIS  275 

supply  to  this  organ,  furnishing-  a  collateral  circulation  denied  to  the 
other  sex.  Functional  disturbance  of  the  bowels,  particularly  constipa- 
tion, precedes  the  attack  with  sufficient  regularity  to  appear  as  an  excit- 
ing cause.  Worms,  both  the  oxyuris  and  lumbricoid,  have  been  found 
in  the  appendix  and  may  act  as  morbific  agents.  The  bacteria  involved 
in  this  inflammation  are  usually  the  pneumo-  and  streptococcus  and  the 
bacterium  coli  communis,  the  last  named  organism  being  rarely  absent. 

Pathology. — The  lesion  may  be  catarrh  of  the  mucous  lining,  ulcera- 
tion, perforation,  or  gangrene,  which  may  be  followed  by  the  secondary 
lesions  of  peritonitis  or  pycemia. 

Despite  the  extended  discussion  given  to  the  subject  of  appendicitis 
during  the  past  two  decades,  anatomical  knowledge  is  still  wanting  in 
regard  to  the  appendix  of  infancy  and  childhood.  It  is  claimed  that  at 
this  period  the  appendix  is  more  funnel-shaped  and  less  liable  to  con- 
strictions in  its  proximal  portions.  Its  irregularity  in  infancy  has  been 
remarked,  both  in  regard  to  its  varying  length  and  the  aberrancy  or 
mobility  of  the  ca?cal  pouch  to  which  it  is  attached.  Thus  it  is  found 
sometimes  in  the  region  of  the  umbilicus,  occasionally  on  the  left  side 
and  rarely  in  the  sac  of  an  inguinal  hernia,  but  almost  always  it  is  in  a 
higher  location  than  is  usual  in  the  adult.  It  is  claimed  that  in  infancy 
the  mesentery  is  frequently  attached  to  the  entire  length,  thus  giving 
to  the  tissues  of  the  appendix  a  relatively  freer  blood  supply. 

Lesions. — Probably  in  a  large  majority  of  instances  the  disease  begins 
as  a  catarrhal  inflammation  and  frequently  terminates  as  such,  with 
merely  the  production  of  lymph.  How  many  of  these  mild  attacks  of 
simple  catarrhal  appendicitis  are  entirely  overlooked  is  a  matter  of 
conjecture.  If  constriction  at  the  neck  or  at  any  other  point  occur,  the 
incarcerated  contents  act  as  a  foreign  body  upon  the  swollen  mucosa. 
This,  with  the  omnipresent  bacterium  coli  communis,  may  light  up  a 
suppurative  or  ulcerative  process  which  may  involve  all  the  layers  of  the 
appendix.  Perforation  by  ulceration  or  by  gangrene,  with  escape  of 
contents  into  the  peritoneal  cavity,  must  result  in  peritonitis.  Whether 
the  peritonitis  be  general  or  circumscribed  depends  upon  the  location 
and  extent  of  the  peritoneal  adhesions.  A  localized  abscess  may  be  due 
to  the  presence  of  plastic  lymph  which  walls  off  the  escaping  pus,  in 
which  the  appendix  seemingly  dissolves.  A  retroperitoneal  abscess  may 
develop  from  invasion  of  that  area  by  pus  germs. 

Symptoms. — The  three  cardinal  symptoms  of  appendicitis  are  local 
abdominal  pain,  tenderness,  and  rigidity  of  the  recti  muscles.  The  pain 
is  intermittent  and  may  be  severe,  acute,  lancinating,  or  colicky.  Usually 
in  infants  and  young  children  the  pain  is  not  definitely  located,  and  when 
referred  by  the  child  to  a  particular  region,  this  is  most  often  the  umbil- 
icus. Occasionally  the  pain  is  slight  or  wanting.  Tenderness  is  seldom 
absent,  and  careful  palpation  may  frequently  locate  it  in  the  right  in- 
guinal region,  although  it  is  sometimes  most  marked  on  the  left  side. 
At  times  the  entire  abdomen  is  hyperaesthetic  either  to  deep  or  super- 
ficial pressure.    Rigidity  of  the  abdominal  muscles  is  most  always  present, 


276 


DISEASES    OF    THE    GASTROENTERIC    TRACT 


especially  in  the  right  lower  quadrant.  Fever  is  a  common  symptom  and 
may  range  from  100.5°  to  105°  F.  (38°-40.5°  C).  The  extent  of  the 
pyrexia  is  not  uniformly  in  keeping  with  the  gravity  of  the  lesion.  In 
contrast  to  the  rather  low  range  of  temperature  the  pulse  of  appendicitis 
is  always  rapid — one  hundred  and  twenty  to  one  hundred  and  sixty  or 
higher — and  is  thin  and  thready  in  character.  Vomiting  is  a  common 
accompaniment  of  severe  attacks,  and  the  tongue  is  usually  furred. 
A  persistent  heavy  coating,  as  in  adults,  is  considered  evidence  of  sup- 
puration. Thirst  or  intense  constipation  is  the  rule,  although  diarrhoea 
may  precede  or  accompany  the  attack.  In  severe  cases  the  face  is 
pale  or  of  leaden  color  and  the  features  are  drawn  and  anxious,  when 
not  distorted  by  paroxysms  of  pain.  The  characteristic  position  of  the 
child  is  in  the  dorsal  decubitus  with  the  right  leg  slightly  drawn  up,  or 
the  knee  may  be  flexed  against  the  abdomen. 

The  onset  may  be  sudden,  resembling  an  attack  of  indigestion,  with 
colic  and  vomiting.  In  the  acute  catarrhal  variety,  all  symptoms  may 
subside  in  forty-eight  hours  without  a  diagnosis  of  appendicitis.    Later, 


Fig.  138. — Palpating  the  appendix. 

if  careful  palpation  be  made  (Fig.  138),  there  may  be  felt  in  the  right 
iliac  region  a  slight  thickening  and  induration  of  the  appendix.  Some- 
times no  evidence  remains.  A  number  of  such  attacks  may  occur 
in  the  course  of  two  or  three  years,  which  in  the  history  of  the  case 
are  given  as  recurrences  of  indigestion.  This  diagnosis  is  discred- 
ited in  many  instances  by  post-mortem  evidences  of  old  inflammatory 
lesions. 

A  severe  suppurative  appendicitis  may  develop  during  the  course 
of  or  after  the  subsidence  of  one  of  these  mild  acute  attacks.  In  this 
event  there  will  be  exacerbation  of  all  the  symptoms,  and  palpation 
after  the  second  or  third  day  may  reveal  the  tumor.  McBurney's  point  is 
rarely  of  any  value  in  the  location  of  lesions  of  the  appendix  in  infants. 

Perityphilitic  abscess,  as  it  was  formerly  called,  may  occasionally 
be  diagnosed  by  the  boggy  feel  of  this  tumor,  the  history  of  chill  in 
older  children,  the  fluctuating  temperature,  the  persistently  furred 
tongue  suggestive  of  sepsis,  the  marked  leucocytosis,  also  by  careful  digi- 
tal exploration  through  the  rectum  and  by  the  aspiration  of  pus  through 
the  hypodermic  needle.  If  the  pus  is  completely  encysted,  marked  septic 
symptoms  and  leucocytosis  subside,  so  that  too  much  stress  should  not 


APPENDICITIS  277 

be  placed  upon  the  leucocyte  count  as  diagnostic.  The  anaemia  of  appen- 
dicitis, especially  in  long-continued  cases,  is  a  well  recognized  fact,  both 
as  to  the  falling  off  of  the  erythrocytes  to  two  <>r  three  millions  per  C.c, 
and  as  to  the  diminution  of  haemoglobin,  which  may  reach  sixty  or  even 
forty  per  cent. 

The  duration  of  appendicular  abscess  is  somewhat  indefinite  and  may 
persist  for  weeks  with  general  symptoms  of  mild  or  severe  septicaemia. 
Occasionally,  after  the  third  or  fourth  day  of  a  mild  attack  of  appendi- 
citis, fulminant  symptoms  develop,  with  extensive  peritonitis,  collapse 
and  death  in  forty-eight  hours ;  the  post-mortem  showing  gangrene  and 
sloughing  of  the  appendix.  Exacerbations  of  temperature,  with  sudden 
rise  in  leucocyte  count  to  more  than  twenty  thousand  per  C.c.  are 
suggestive  of  extension  of  the  suppurative  process.  Rupture  may  occur 
with  discharge  of  contents  into  the  bowel,  followed  by  subsidence  of 
symptoms  and  rather  prompt  recovery.  If  the  abscess  opens  into  the 
peritoneal  cavity,  acute  symptoms  of  general  peritonitis  develop,  such  as 
pain,  abdominal  distention,  and  tympanitis,  weak  and  thready  pulse  and 
collapse.  Peritonitis,  whether  circumscribed  or  general,  is  always  accom- 
panied by  rapid  increase  in  leucocytes,  unless  the  prostration  is  so  ex- 
treme as  to  lower  the  resistance  beyond  response  to  the  infection.  In  this 
case  death  is  an  early  termination. 

Diagnosis. — The  diagnosis  of  appendicitis  from  other  acute  condi- 
tions with  similar  symptoms  is  often  extremely  difficult.  Acute  indiges- 
tion or  constipation  with  colic  and  impacted  caecum  may  simulate  ap- 
pendicitis, although  in  the  former  the  higher  temperature  and  early  sub- 
sidence of  acute  symptoms,  while  in  the  latter  absence  of  tenderness  and 
abdominal  rigidity,  should  reveal  the  character  of  this  disorder.  Obstruc- 
tion of  the  bowel  from  volvulus  or  acute  intussusception  may  lead  to  a 
suspicion  of  appendicitis.  The  absence  of  fever,  the  presence  of  bloody 
mucoid  discharges  from  the  rectum,  and  the  demonstration  of  the  char- 
acteristic tumor  of  the  left  side,  should  dispel  doubt. 

Hepatic  and  renal  colic  are  rarely  accompanied  by  fever  and  localized 
tenderness  in  the  right  iliac  fossa. 

Psoas  or  perinephritic  abscess  should  be  distinguished  from  one  of 
appendicular  origin  by  the  preceding  history  and  symptoms  pointing  to 
dorsal  spondylitis  in  the  former  and  occasionally  by  the  urinary  findings 
in  the  latter. 

In  typhoid  conditions  the  Widal  test  should  be  applied,  and  the  pos- 
sibility of  peritonitis  from  perforating  typhoidal  ulcer  should  not  be 
forgotten. 

A  number  of  cases  of  coexisting  enterocolitis  and  appendicitis  have 
been  reported.  In  young  infants  the  common  occurrence  of  the  former 
and  the  rarity  of  the  latter  should  be  kept  in  mind,  although  in  all  cases 
careful  palpation  of  the  abdomen  should  be  practised. 

Pneumonia  in  young  children,  especially  of  the  lower  right  lobe,  very 
frequently  occasions  abdominal  pain  and  tenderness  from  pleuritic  in- 
volvement of  the  lower  dorsal  nerves.     A  careful  examination  of  the 


278        DISEASES    OF    THE    GASTROENTERIC    TRACT 

chest,  and  search  for  the  characteristic  disturbance  of  the  pulse- 
respiration  ratio  should  establish  a  diagnosis  as  to  lung  lesion. 

In  children  acute  peritonitis  should  always  lead  to  a  suspicion  of 
appendicitis  as  a  cause,  although  it  should  be  remembered  that  infection 
from  gonorrhceal  vulvovaginitis  may  extend  to  the  peritoneal  cavity,  and 
that  tuberculosis  of  the  peritoneum  is  common  enough  in  infancy  and 
childhood.  In  fact,  tubercular  ulceration  may  be  the  primary  lesions  in 
appendicitis. 

Prognosis. — The  prognosis  of  appendicitis  in  children  should  always 
be  regarded  as  grave,  since  the  extreme  variability  and  uncertainty  of 
its  course  render  the  statistics  of  recovery  of  little  prognostic  value  in 
any  given  case. 

Too  often  a  record  of  successfully  treated  cases  is  interrupted  by  sud- 
den fatality,  which  should  serve  as  a  constant  reminder  of  the  uncer- 
tainty of  any  medicinal  method  of  treatment.  To  be  on  the  safe  side 
the  disease  should  be  regarded  as  surgical  from  first  to  last.  The 
objections  to  an  operation  rarely  weigh  against  its  advantages.  The  ar- 
gument that  many  cases  recover  under  medical  treatment  is  offset  by  the 
well  known  tendency  to  recurrent  attacks  of  the  disease.  The  diametri- 
cally opposite  practice  among  our  best  physicians  in  regard  to  the  use 
of  laxatives  and  opium  is  in  itself  an  argument  in  favor  of  surgery. 

When  the  diagnosis  of  appendicitis  is  established  the  surgeon  should 
be  called  in  consultation.  Meanwhile  reason  teaches  and  experience  has 
proven  the  value  of  opium  for  the  relief  of  the  pain,  and  of  the  local  appli- 
cation of  the  ice-bag  over  the  lesion.  The  child  must  be  kept  absolutely 
quiet  in  bed  during  even  the  mildest  attack.  A  preliminary  cleaning 
out  of  the  bowels  with  a  full  dose  of  calomel,  one  to  five  grains  (0.065- 
0.3  Gm.),  with  sodium  bicarbonate,  two  to  five  grains  (0.13-0.3  Gm.), 
may  be  advisable,  after  which  the  colon  may  be  occasionally  unloaded 
by  moderate  enemata  of  saline  solutions.  Pood  should  be  absolutely 
withheld  and  water  sparingly  given,  if  at  all.  Morphine  hypodermically 
in  doses  barely  sufficient  to  relieve  severe  pain  is  indicated.  If  the  ice- 
bag  is  not  well  borne,  hot  applications  may  afford  relief.  The  constant 
danger  of  peritonitis  and  its  extreme  fatality  in  young  children  should 
never  be  lost  sight  of,  against  which  must  be  remembered  the  low  mor- 
tality of  early  surgery. 

PROCTITIS  AND  RECTAL  ULCERATION. 

Proctitis  is  an  inflammation  of  the  rectum  and  often  accompanies 
enterocolitis.  It  may,  however,  occur  independently  of  catarrhal  con- 
ditions of  the  upper  bowel.  In  this  case  it  may  be  due  to  bacterial  in- 
fection through  the  anus.  Tubercular  and  syphilitic  lesions  are  also 
found  in  the  rectum,  and  traumatisms  with  resultant  infections  may 
lead  to  ulceration.  Such  injuries  are  frequently  the  result  of  ignorance 
or  carelessness  in  the  use  of  thermometer  or  rectal  tube,  and  of  the  abuse 
of  suppositories  in  rectal  medication.  Parasites,  as  the  oxyuris  vermicu- 
laris,  may  cause  inflammation.     In  diphtheria  of  the  genitals  we  may 


PROCTITIS  279 

have  a  membranous  proctitis;  whereas  tubercular  and  gonorrheal  in- 
fection of  the  rectum  always  produces  ulcers  which  are  usually  located 
just  above  the  inner  sphincter. 

Symptoms. — The  symptoms  are  pain,  tenesmus,  and  discharges  of 
mucus,  very  often  accompanied  by  blood  and  pus.  The  sphincters  are 
frequently  relaxed.  There  may  be  pouting  of  the  anal  mucosa  or  ex- 
tensive prolapse  of  the  rectum.  The  ulcerations  are  usually  shallow, 
though  they  may  perforate  the  intestinal  wall  and  form  ischiorectal  ab- 
scesses. These  tend  to  extensive  burrowing  and  destruction  of  tissue. 
If  situated  near  the  margin  of  the  sphincter  they  lead  to  fistulous  open- 


Fig.  139. — Position  of  infant  for  introduction  of  thermometer. 

ings  into  the  gut,  as  well  as  to  the  surface.  No  diagnosis  is  necessary, 
save  as  to  the  variety  and  cause  of  the  lesion,  upon  which  depends  the 
mode  of  treatment. 

Treatment. — For  the  treatment  of  proctitis  complicating  iliocolitis, 
sufficient  has  been  said  under  that  subject.  Simple  catarrhal  inflamma- 
tion of  the  rectum  usually  yields  promptly  to  the  removal  of  the  cause, 
as  worms,  constipation,  polypus,  etc.  Careful  irrigation  with  saturated 
boric  acid  solution,  and  suppositories  of  opium  and  belladonna  to  relieve 
the  pain  and  tenesmus,  may  be  used.  Gonorrheal  infection  requires 
prompt  bactericidal  injections,  such  as  protargol  solution,  two  to  five 
per  cent.,  or  nitrate  of  silver  in  similar  solution,  which  should  be  neu- 
tralized by  salt  solution.  Rectal  ulcers  often  prove  extremely  obstinate 
and  may  be  very  painful  if  in  close  proximity  to  the  sphincter.  They 
give  rise,  at  times,  to  sufficient  hemorrhage  to  cause  anosmia.    The  general 


280        DISEASES    OF    THE    GASTRO-ENTERIC    TRACT 

health  may  be  impaired,  which  condition  increases  the  intractability 
of  the  local  lesion  from  the  lowered  vitality  of  the  tissues.  The  ulcers 
should  be  freely  irrigated  with  permanganate  of  potassium  (1  :  1000) 
twice  daily.  Cocaine,  morphine,  belladonna,  or  suprarenal  extract,  may 
each  prove  useful  in  relieving  pain  and  diminishing  hyperemia.  It  may 
be  necessary  to  introduce  a  speculum  and  touch  the  ulcers  with  solid 
nitrate  of  silver  every  second  or  third  day.  Frequent  applications  of 
iodoform  or  aristol  are  found  beneficial.  If  an  abscess  form  outside 
the  boAvel  it  should  be  freely  opened,  drained,  cleaned  and  treated  ac- 
cording to  the  usual  surgical  method.  Syphilitic  and  tubercular  lesions, 
aside  from  their  local  treatment,  call  for  constitutional  treatment,  which 
is  discussed  under  their  separate  heads. 

Prophylaxis  is  important  in  the  prevention  of  proctitis  by  the  early 
removal  of  the  causative  conditions  and  by  care  in  the  clinical  and  thera- 
peutic invasion  of  the  bowel.  A  study  of  the  rectum  shows  that  the 
axis  of  the  outlet,  instead  of  running  parallel  with  the  long  axis  of  the 
body,  points  backward  at  an  angle  of  forty-five  degrees,  so  that  entrance 
to  the  gut  must  be  from  behind  to  avoid  impinging  against  the  wall  of 
the  viscus.  The  practice  of  introducing  a  hard  tube,  or  the  sharper 
thermometer  from  between  the  thighs,  frequently  causes  abrasions  of 
the  softened  mucosa  of  the  posterior  wall  which  it  meets  at  a  right  angle. 
Fig.  139  shows  the  direction  of  the  anal  outlet  and  the  proper  position  of 
the  infant  for  the  introduction  of  the  thermometer. 

PROLAPSE  OP  THE  RECTUM  AND  ANUS. 

Prolapsus  ani  is  not  uncommon  in  infancy  and  early  childhood.  The 
mucous  membrane  of  the  anus  may  alone  protrude  with  eversion  of  the 
external  sphincter,  or  the  lower  portion  of  the  rectum  may  pass  through 
the  sphincter  and  appear  as  an  invaginated  dark-red  or  purplish  tumor 
protruding  from  the  anus  to  the  distance  of  two  or  three  inches  (5-8 
Cm.). 

Etiology. — Its  frequent  occurrence  in  childhood  is  explained  by  the 
immature  condition  of  the  sphincter  muscles,  by  the  redundancy  of  the 
infant  rectum,  its  straight  lower  third,  the  loose  attachment  to  the  shal- 
low pelvis  and  the  want  of  development  of  the  levatores  ani.  The  descent 
of  the  rectum  is  induced  in  debilitated  infants  by  much  straining  due  to 
constipation,  proctitis,  difficult  micturition,  or  paroxysms  of  whooping- 
cough.  It  occurs  most  frequently  during  the  relaxed  conditions  attend- 
ing diarrhcea.  Any  condition  which  favors  muscular  atony  and  absorp- 
tion of  fat  predisposes  to  rectal  prolapse,  hence  rickets  and  marasmus 
have  been  ascribed  as  causes.  Rectal  polypi,  by  their  teasing  presence, 
may  induce  eversion  of  the  anus  and  bring  on  prolapse. 

The  symptoms  are  easily  recognized  and  are  to  be  distinguished  from 
those  of  hemorrhoids,  polypi,  and  intussusception.  If  the  case  be  not 
severe  the  prolapsed  portion  returns  shortly  after  the  bowel  movement. 

Treatment. — Its  return  is  facilitated  by  oiling  the  protruding  mass 
and  inverting  the  child  while  gentle  pressure  is  made  with  the  fingers 


FISSURE    OF    THE    ANUS  281 

covered  with  gauze.  If  much  congestion  and  tumefaction  have  occurred, 
ice  may  be  applied  or  the  mucosa  may  be  painted  with  a  two  per  cent, 
solution  of  cocaine,  or  a  solution  of  suprarenal  extract  may  be  used  to 
deplete  the  vessels.  Exceptionally  it  may  be  necessary  to  dilate  the 
sphincter  by  introducing  two  fingers  through  the  invaginated  portion. 
In  older  children  suspension  by  the  arms  will  aid  in  dragging  the  ab- 
dominal viscera  upwards.  To  prevent  recurrence,  constipation,  if  it 
exist,  must  be  relieved  by  mild  laxatives  and  clysters  of  cold  water, 
while  mild  astringents,  as  alum,  tannin,  or  adrenalin  solutions,  may  be 
applied.  Children  should  not  be  allowed  to  strain  during  defecation.  To 
this  end  the  infant  should  lie  on  his  side,  or  the  perineum  may  be  sup- 
ported or  buttocks  compressed  by  the  hands  of  the  nurse.  Older  chil- 
dren should  have  the  commode  elevated  so  that  the  feet  may  not  rest 
upon  the  floor,  or  the  seat  may  be  given  a  forward  slant.  The  custom 
of  allowing  children  to  sit  for  a  long  time  at  stool  is  harmful.  After  a 
movement  the  horizontal  position  should  be  maintained  for  a  half  hour 
or  more. 

A  pad  may  be  placed  against  the  anus  and  retained  by  a  T-bandage,  or 
a  broad  strip  of  adhesive  plaster  may  be  applied  so  as  to  hold  the  but- 
tocks together  and  thus  support  the  anus. 

Nux  vomica  and  ergot  may  be  given  to  tone  up  the  muscular  system, 
or  hypodermic  injections  of  strychnine  or  ergotine  in  the  vicinity  of 
the  anus  may  be  of  more  advantage  in  severe  cases. 

All  measures  to  improve  nutrition  should  be  employed. 

The  prognosis  is  good,  but  in  rare  cases  surgical  methods  must  be 
resorted  to. 

FISSURE  OF  THE  ANUS. 

Fissure  of  the  anus  in  infants  and  young  children  is  of  frequent 
occurrence  and  may  be  due  to  the  passage  of  hard,  dry  scybala  and 
traumatisms,  as  from  scratching  or  the  careless  introduction  of  thermom- 
eters or  syringes. 

These  fissures  give  rise  to  severe  pain  at  defecation  and  for  some 
time  after.  They  are  frequently  the  cause  of  fecal  retention  and  con- 
stipation. The  spasmodic  action  of  the  sphincter  prevents  healing  of 
the  lesion  which  may  proceed  to  ulceration.  The  child  is  irritable  and 
presents  symptoms  of  reflex  nervous  disturbances  which  may  seriously 
impair  nutrition. 

The  treatment  is  simple.  Cleanliness  and  a  few  applications  of  ni- 
trate of  silver,  followed  by  a  bland  ointment,  with  measures  for  the  relief 
of  the  constipation,  will  usually  effect  a  cure.  Obstinate  cases  may  re- 
quire stretching  of  the  sphincter  to  overcome  spasmodic  action  and 
allow  healing.  This,  of  course,  should  be  done  only  under  complete 
anaesthesia. 

RECTAL  POLYPI. 

Polypoid  growths  in  the  rectum,  although  rarely  seen  in  young  in- 
fants, are  common  after  the  second  year.     They  are  usually  single,  pe- 


282        DISEASES    OP    THE    GASTRO-ENTERIC    TRACT 

dunculated,  and  situated  on  the  posterior  wall  of  the  rectum,  from  one 
to  two  inches  above  the  internal  sphincter.  They  may,  however,  be 
multiple,  more  or  less  sessile,  and  located  in  different  parts  of  the  rectum, 
sigmoid,  descending  colon,  or  even  the  ceecum.  They  may  vary  in  size 
from  a  split  pea  to  a  cherry. 

Two  varieties  are  recognized,  first,  the  myxomatous  or  myxofibroma- 
tous,  and,  second,  the  adenomatous.  The  former  is  always  benign;  the 
latter  may  develop  malignant  characteristics.  Although  it  was  formerly 
taught  that  the  simple  mucoid  polyp  was  the  one  most  frequently  found 
in  the  rectum,  later  investigations  have  proved  that  the  lymphoid  variety 
is  the  one  with  which  the  pediatrist  has  most  frequently  to  deal.  There  is 
good  reason  to  believe  that  it  occurs  in  association  with  adenoid  hyper- 
plasia in  other  parts  of  the  body  as  a  result  of  that  diathesis,  the  status 
lymphaticus,  or  lymphatism. 

Unquestionably  the  presence  of  these  tumors  frequently  escapes  rec- 
ognition, as  they  may  be  expelled  by  rupture  of  their  attenuated  pedicles. 

The  first  symptom  is  usually  bright  blood  which  coats  the  stool  but 
is  not  mixed  with  the  faeces.  Occasionally  uneasy  sensations  in  the  rec- 
tum, continual  tenesmus  and  pruritus,  attract  attention.  Anal  fissures 
are  frequently  associated  with  rectal  polypi.  Considerable  loss  of  blood 
has  been  known  to  occur  from  this  cause,  resulting  in  marked  anasmia. 

The  diagnosis  is  made  by  digital  exploration.  Occasionally  the  polyp 
may  be  seen  after  a  bowel  movement,  presenting  at  the  anal  orifice  as  a 
smooth  dark  red  body. 

The  treatment  is  by  removal,  which  the  usually  long  pedicle  renders 
easy.  If  the  operator  fears  the  rare  occurence  of  hemorrhage  from  tor- 
sion, removal  may  be  done  by  ligation  or  the  snare,  through  a  speculum. 
If  the  presence  of  polypoid  tumors  be  diagnosed  in  the  colon  by  palpa- 
tion through  the  abdominal  wall,  their  removal  must  be  by  incision  and 
colotomy. 

HEMORRHOIDS. 

The  possibility  of  hemorrhoids,  although  of  rare  occurrence  in  child- 
hood, should  be  kept  in  mind  in  the  diagnosis  of  anal  prolapse  and  rec- 
tal polypus.     Two  or  even  all  of  these  conditions  may  be  coexistent. 

The  treatment  of  hemorrhoids  in  children  does  not  differ  from  that 
in  adult  life. 


CHAPTER    VII 
DISEASES  OF  THE  LIVER  AND   PANCREAS 

CONGESTION  OF  THE  LIVER 

Congestion  of  the  liver,  although  strictly  speaking  not  a  disease,  is 
a  condition  which  precedes  every  structural  disorder  of  that  organ. 
Its  early  recognition  and  relief,  therefore,  are  not  only  important  for 
the  restoration  of  normal  metabolism,  but  for  the  arrest  of  those  anatomic 
changes — such  as  hemorrhages,  cloudy  swelling,  parenchymatous  and 
fatty  degeneration,  and  hyperplasia  of  connective  tissue — which  may 
ultimately  lead  to  irreparable  structural  lesions  of  the  liver. 

Some  writers  claim  for  the  developing  period  a  comparative  immunity 
from  this  condition  which  is  of  so  common  occurrence  in  mature  life. 
Analysis  of  the  facts,  however,  will  hardly  bear  out  this  claim. 

Hepatic  congestion  is  usually  considered  as  active  or  passive.  Of  the 
former  the  attributable  causes  are  overfeeding,  too  rich  food,  acute  in- 
fections, acute  gastroduodenal  catarrh,  chilling  and  shock.  To  all  of 
these  the  infant  or  child  is  as  frequently  subject  as  the  adult,  or  even 
more  so. 

The  passive  form  may  be  due  to  cardiac  incompetency,  pulmonary  ob- 
struction from  pneumonia,  emphysema,  or  atelectasis,  pleuritis,  chronic 
gastroenteritis,  climatic  conditions,  syphilis  and  malarial  poisoning,  any 
one  of  these,  singly  or  in  combination. 

With  the  exception  of  the  less  frequent  syphilis,  structural  heart 
lesions,  and  emphysema,  the  child  enjoys  no  exemption  from  these  causes. 
Moreover,  to  the  careful  observer  the  eight-year-old  heart  may  show  in- 
competency as  frequently  as  does  that  of  the  adult,  and  partial  atelectasis 
or  pulmonary  collapse  in  the  infant  is  of  more  common  occurrence  than 
adult  emphysema. 

The  subjective  symptoms  of  hepatic  congestion  are  often  overlooked 
in  early  childhood  or  incorrectly  interpreted.  The  hepatic  enlargement 
is  considered  normal  to  that  age.  The  alcoholic  stools  of  the  infant  are 
attributed  to  the  milk  diet,  while  the  headache  and  malaise  are  disre- 
garded. Scorbutus,  now  rarely  seen  in  adult  life,  keeps  pace  with  the 
increasing  prevalence  of  artificial  feeding. 

The  treatment  of  hepatic  congestion  consists  in  the  correction  of  the 
diet,  especially  in  regard  to  the  overingestion  of  fats,  carbohydrates,  alco- 
hol, and  coffee.  Depletion  of  the  engorged  hepatic  vessels  should  be 
secured  by  the  use  of  calomel  three  to  ten  times  every  twenty-four  hours, 
or  sodium  phosphate,  given  in  milk  or  used  as  a  condiment  in  place  of 
sodium  chloride,  until  its  purgative  action  is  secured.     For  older  chil- 

283 


284  DISEASES    OF    THE    LIVER 

dren  ammonium  chloride  is  useful.  Water  is  always  indicated,  especially 
the  alkaline  and  saline.  In  prolonged,  obstinate  cases,  this  treatment  may 
be  followed  by  a  course  of  dilute  nitrohydrochloric  acid,  well  diluted. 
Massage  and  exercise  in  the  open  air  are  important. 

The  treatment  for  the  passive  form  of  congestion  consists  princi- 
pally in  relief  for  the  primary  disorder. 

ACUTE  INFECTIOUS  LIVER. 

It  has  long  been  known  that  during  the  course  of  most  of  the  acute 
infectious  diseases  constant  and  marked  changes  occur  in  the  liver. 
Those  most  frequently  found  are  active  hyperemia,  dilatation  of  ves- 
sels, round-cell  infiltration,  formation  of  new  tissue,  parenchymatous 
and  fatty  degeneration  and  consequent  interference  with  function. 

Usually  the  hepatic  disturbance  subsides  upon  recovery  from  the 
primary  disorder,  but  convalescence  may  be  interrupted  by  symptoms 
of  acute  infection  of  the  liver.  There  are  chills,  recurrent  and  irregular 
pyrexia,  malaise,  prostration,  anorexia  and  vomiting.  Palpation  will 
disclose  enlargement  and  tenderness  of  the  liver  and  other  symptoms  of 
hepatic  abscess.  For  weeks  and  even  months  the  temperature  may  show 
fluctuations  suggestive  of  sepsis.  The  urine  may  contain  blood,  albumin, 
and  casts. 

Recovery  is  slow,  with  gradual  subsidence  of  all  the  symptoms,  the 
liver  finally  regaining  its  normal  size  and  consistency. 

Post-mortems,  in  fatal  cases,  disprove  the  existence  of  abscess. 

The  treatment  is  symptomatic  and  supportive. 

SUPPURATIVE   HEPATITIS — ABSCESS   OP   THE   LTVER. 

Since  hepatic  abscess  may  be  due  to  traumatism,  empyema,  perity- 
phlitis, pelvic  peritonitis,  umbilical  phlebitis,  dysentery,  lumbricoids 
in  the  bile  ducts,  tuberculosis,  or  other  infectious  diseases,  children  are 
prone  to  this  disorder  in  proportion  to  their  proneness  to  the  causative 
conditions. 

The  signs  and  symptoms  of  suppurative  hepatitis  have  no  special 
characteristics  in  infancy.  Usually  hepatic  pain  is  less  prominent  and 
may  be  wanting.  The  normally  large  liver,  especially  when  increased 
by  congestion,  may  lead  the  practitioner  to  a  mistaken  diagnosis  of 
abscess  in  his  efforts  to  locate  a  suspected  collection  of  pus.  The  oc- 
casional interposition  of  the  bowel  between  the  low,  rounded  margin  of 
the  liver  and  palpating  finger,  may  yield  the  variation  in  density  and  even 
the  fluctuation,  described  by  some  as  diagnostic  of  anterior  or  marginal 
abscess  of  the  liver.  So,  also,  pressure  upon  the  right  hypochondrium 
may  by  upward  displacement  elicit  pain  in  the  infant,  due  to  an  unsus- 
pected pleurisy. 

With  rare  exceptions,  exploratory  aspiration  alone  may  demonstrate 
the  presence  of  abscess,  single  or  multiple. 

The  prognosis  of  a  single  abscess  is  favorable  in  proportion  to  the 


CIRRHOSIS    OF    THE    LIVER  285 

probability  of  its  rupture  externally  or  into  the  bowel.     Multiple  ab- 
scesses are  necessarily  fatal. 

The  treatment  is  essentially  surgical. 

CIRRHOSIS  OF  THE  LIVER. 

Cirrhosis  of  the  liver  is  more  common  in  infancy  and  childhood  than 
was  formerly  supposed.  Reported  cases  now  number  many  hundreds. 
The  condition  may  be  congenital,  although  in  all  probability  such  cases 
are  due  to  syphilitic  affections  of  this  organ.  No  good  reason  is  ap- 
parent why  syphilitic  cirrhosis  should  be  included  in  a  general  descrip- 
tion of  this  disorder,  since  the  effect  upon  the  hepatic  function  differs 
little,  if  any,  from  other  forms;  nor  is  it  necessary  to  attempt,  in  this 
limited  work,  a  refined  differentiation  between  the  two  forms, — namely, 
hypertrophic  and  atrophic  cirrhosis.  A  study  of  reported  cases  shows 
that  in  children  enlargement  of  the  liver  preceded  atrophy  in  nearly 
every  instance.  The  fact  that  the  autopsies  show  a  large  preponderance 
of  atrophic  cases  proves  only  the  terminal  condition  of  the  liver,  which 
might  have  shown  hypertrophy  in  its  initial  stage.  Infants  show  a 
higher  percentage  of  the  hypertrophic  form  than  do  adults.  This,  again, 
may  be  due  to  the  fact  that  infants  succumb  more  rapidly  to  the  inter- 
ference with  metabolism  and  toxasmia. 

Hepatic  cirrhosis  may  be  due  to  chronic  passive  congestion  from  car- 
diac or  renal  disease,  an  increasing  stenosis  of  the  bile  ducts,  or  con- 
genital occlusion  of  the  same.  Syphilis,  tuberculosis,  and  malaria  are 
common  causative  factors.  The  frequency  with  which  it  has  been  pre- 
ceded by  acute  infections,  especially  scarlet  fever  and  measles,  gives 
color  to  the  claim  of  their  influence  in  its  development.  Rhachitis  is  not 
uncommonly  mentioned  in  the  histories  of  infantile  hepatic  cirrhosis. 
Undoubtedly  ptomaine  poisoning  in  the  marasmic  and  in  children  with 
gastroduodenal  catarrh,  must  not  be  overlooked  as  at  least  a  predispos- 
ing cause.  The  ignorance  of  parents  in  regard  to  the  effect  of  the  use 
of  coffee,  tea,  and  alcoholic  stimulants,  is  responsible  for  a  large  per- 
centage of  cirrhotic  livers.  The  effects  of  these  poisons  are  especially 
noticeable  in  the  growing  organism. 

The  symptomatology  and  diagnosis  do  not  differ  essentially  from 
those  of  adult  cases.  Ascites,  usually  a  late  sign,  emphasizes  the  gravity 
of  the  condition.  Icterus  is  usually  present  in  some  degree.  Convul- 
sions are  of  more  frequent  occurrence  than  in  later  life.  The  course  is 
more  rapid. 

The  prognosis,  always  grave,  is  brightened  in  syphilitic  cases  where 
the  heroic  use  of  mercurials  and  iodides  have  proved  efficacious.  Non- 
syphilitic  cases,  also,  have  improved  under  these  agents.  No  case  should 
be  pronounced  hopeless  when  we  recall  the  recuperative  energy  of  young 
tissue. 

Treatment. — A  recognition  of  the  predisposition  should  lead  us  to 
the  early  treatment  of  gastroduodenal  catarrhs  and  hepatic  congestion 
in  children,  especially  in  those  with  incompetent  hearts,  or  during  con- 


286  DISEASES    OF    THE    LIVER 

valescence  from  acute  infections.  The  same  is  true  after  shocks,  burns, 
and  exposures  to  cold.  The  actual  hyperplasia  of  Glisson's  capsule,  in 
the  early  stages,  may  be  diminished  by  the  use  of  calomel  in  one-tenth  to 
one-fourth  grain  (0.006-0.016  Gm.)  doses,  four  times  a  day,  or  daily 
inunctions  of  mercurial  ointment,  ten  to  twenty  grains  (0.65-1.38  Gm.), 
while  the  biliary  stasis  may  be  relieved  by  the  continuous  use  of  am- 
monium chloride  in  doses  of  two  to  ten  grains  (0.13-0.65  Gm.)  every 
four  hours.  Saline  aperients — as  sodium  sulphate,  phosphate,  and  mag- 
nesium citrate — should  be  given  to  the  extent  of  three  or  four  liquid 
stools  daily.  The  frequent  accompanying  renal  cirrhosis  should  not  be 
overlooked.  Such  diuretics  as  calomel,  squills,  copaiba,  alternating  with 
potassium  acetate  and  citrate,  should  be  administered  to  secure  free 
elimination  by  the  kidneys. 

The  best  of  hygiene  is  necessary  with  only  moderate  exercise.  The 
diet  should  include  proteids  that  are  easily  digested,  avoiding  excessive 
ingestion  of  fats  with  only  a  moderate  amount  of  starchy  and  saccharine 
material.  Fruits,  soups  and  broths  should  be  given,  but  milk  should  be 
made  the  main  article  of  diet. 

ACUTE  YELLOW  ATROPHY  OP   THE  LIVER. 

Acute  yellow  atrophy  of  the  liver  is  very  rare  in  infancy  and  child- 
hood. Recently  two  such  cases  have  been  reported, — one  in  an  infant 
of  one  month,  and  the  other  in  a  new-born  child.  The  symptoms  and 
post-mortem  findings  differ  but  little  from  those  seen  in  adults. 

The  effects  of  some  mineral  poisons,  as  phosphorus,  antimony  and 
arsenic,  are  so  similar  to  the  symptoms  of  acute  yellow  atrophy  as  to  sug- 
gest that  some  agent  which  produces  general  intoxication  with  selective 
action  on  the  liver  is  probably  the  primary  etiologic  factor  in  this  disease. 

Recoveries  of  two  children  from  acute  yellow  atrophy  are  on  record. 

Until  the  cause  is  better  understood,  all  treatment  remains  unsatis- 
factory. Efforts  should  be  made  to  correct  the  accompanying  gastro- 
duodenal  catarrh,  and  general  supporting  treatment  given. 

FATTY  LIVER. 

Fatty  liver  is  found  most  frequently  in  children  subject  to  wasting 
disease,  especially  tuberculosis.  It  may  accompany  chronic  gastro- 
intestinal indigestion  and  is  usually  developed  in  pale,  angemic,  fat  ba- 
bies, with  large  abdomens  and  other  evidences  of  rickets. 

It  has  also  been  found  in  apparently  robust  children  who  eat  exces- 
sive quantities  of  fatty  and  saccharine  foods.  Overfeeding,  with  the 
absence  of  exercise  and  fresh  air,  will  develop  fatty  liver  in  the  absence 
of  any  other  positive  disorder,  excepting  a  mild  indigestion. 

The  symptoms  are  enlargement  of  the  liver,  without  tenderness,  pain, 
icterus,  or  ascites. 

The  treatment  is  that  of  the  affection  upon  which  it  depends, — cor- 
rection of  the  diet  and  exercise  of  the  muscles,  or  massage  when  the 
latter  is  impracticable.    Depletion  of  the  portal  congestion,  by  mercurials 


AMYLOID    DEGENERATION  287 

and  salines,  will  materially  assist  in  the  recovery  when  not  dependent 
upon  some  primary  incurable  disease. 

AMYLOID   DEGENERATION   OF   LIVER,    KIDNEY,    SPLEEN,    ETC. 

Although  the  precise  defect  in  metabolism  which  permits  the  deposit 
of  amyloid  substance  in  the  middle  coat  of  the  arterioles,  resulting  in  the 
peculiar  anatomic  change  known  as  waxy  liver,  lardaceous  kidney,  sago 
spleen,  or  amyloid  degeneration  of  gastro-intestinal  villi,  thyroid  and 
other  glandular  structures,  is  not  definitely  known ;  a  remote  etiologic  or 
predisposing  factor  is  recognized  in  chronic  tuberculous  and  syphilitic 
processes,  especially  those  of  long  standing  or  of  suppurative  nature,  as 
osteitic,  subperiostitic  and  arthritic  affections.  For  this  reason  amyloid 
degeneration  is  of  special  interest,  as  children  are  particularly  prone 
to  such  suppurative  diseases  of  the  bones. 

The  symptoms  in  childhood  offer  no  conspicuous  difference  from  those 
seen  in  the  adult.  This  condition  of  the  liver  may  be  suspected  when 
marked  enlargement  of  this  organ  is  present,  unaccompanied  by  pain, 
tenderness  or  evidences  of  arrested  hepatic  function,  with  splenic  enlarge- 
ment, in  a  long-standing  case  of  suppurative  cachexia. 

The  prognosis  is  hopeless  unless  the  cause  of  the  cachexia  can  be 
removed,  and  that  early  in  the  history  of  the  amyloid  deposition, — in 
fact,  operations  in  advanced  cases  are  contraindicated. 

HYDATIDS  OP  THE  LrVER. 

Reports  of  foreign  observers  show  that  hydatid  disease  of  the  liver 
is  occasionally  seen  in  children.  In  America,  however,  few  cases  are  on 
record.  The  reason  for  this  infrequency  is  not  apparent,  unless  it  be 
due  to  the  fact  that  hydatid  cysts  require  a  long  period  of  time  for 
their  development,  so  that  the  echinococcus  of  infancy  may  pass  unob- 
served until  the  occurrence  of  the  pronounced  symptoms  in  mature  life. 
In  childhood,  moreover,  on  account  of  the  yielding  character  of  the  walls 
and  surrounding  tissues,  pressure  symptoms  are  less  marked.  Otherwise 
the  history  presents  no  special  peculiarities. 

Treatment. — Surgery  furnishes  the  only  relief,  outside  of  spontaneous 
rupture. 

TUMORS  OP  THE  LIVER. 

Neoplasms  of  the  liver  are  so  rarely  seen  in  infancy  and  childhood 
that  some  recent  writers  make  no  mention  of  them.  Adenomata,  how- 
ever, are  found  at  an  early  age,  and  undoubted  cases  have  been  reported 
of  malignant  carcinomatous  and  sarcomatous  growths,  even  in  infancy. 

The  fact  that  hepatic  cancer  is,  in  some  instances,  secondary  to  chole- 
cystitis or  obstructive  calculi  gives  color  to  the  claim  that  prenatal  in- 
flammation of  the  biliary  structures  may  precede  the  malignant  neo- 
plasm in  early  life. 

The  gloomy  prognosis  of  cancer  stimulates  the  hope  that  the  promise 
of  successful  hepatic  resection  may  see  an  early  fulfilment. 


288  DISEASES    OF    THE    PANCREAS 

SYPHILITIC   PANCREATITIS. 

Probably  the  most  common  pancreatic  disease  of  infancy  is  syphilitic 
cirrhosis,  which  has  been  reported  in  an  advanced  stage  as  early  as  the 
third  month  of  life.  In  syphilitic  pancreatitis  there  is  rarely  glycosuria, 
as  the  islands  of  Langerhans  maintain  their  functional  activity  in  spite 
of  the  general  connective  tissue  overgrowth.  As  in  most  of  the  pancre- 
atic diseases,  the  purely  alimentary  secretion  is  interfered  with,  excess 
of  fat  in  the  stools  being  a  common  result. 

Pancreatic  tuberculosis  appears  in  childhood,  not  only  as  part  of  a 
general  tuberculous  invasion,  but  also  as  a  primary  lesion. 

Cysts  of  the  pancreas  are  of  occasional  occurrence  and  have  been 
reported  in  infants  of  such  tender  age  as  to  suggest  prenatal  origin. 
Cysts  may  be  caused  by  occlusion  of  the  pancreatic  duct  by  calculi,  or 
by  a  biliary  calculus  in  the  common  duct.  The  obstruction  has  in  sev- 
eral instances  been  due  to  lumbricoides.  Parasitic  cysts,  also,  have  been 
found.  Cystic  formation  is  due  most  frequently  to  traumatism.  Pan- 
creatitis by  infection  through  the  duct  of  Wirsing  from  adjacent  duo- 
denal catarrh  is  possible.  This  organ  may  be  involved  in  general  amyloid 
degeneration  without  causing  symptoms.  Abscesses  of  the  pancreas  are 
reported,  as  in  pysemia  and  variola. 

Diagnosis  of  pancreatic  inflammation  is  extremely  difficult.  Among 
the  symptoms  noted  are  epigastric  pain  and  tenderness,  extending  toward 
the  right  shoulder,  more  or  less  vomiting,  and  sometimes  symptoms 
which  resemble  intestinal  obstruction.  However,  there  may  be  diar- 
rhoea, with  excess  of  fat  in  the  stools,  and  glycosuria.  The  presence  of 
a  cyst  or  neoplasm,  if  large  enough,  may  be  diagnosed  by  its  location, 
especially  if  accompanied  by  some  of  the  symptoms  above  mentioned. 
Hemorrhage  into  the  pancreas  may  be  quickly  fatal. 

In  the  treatment  of  non-malignant  pancreatitis  predigested  foods 
are  indicated,  with  the  administration  of  pancreatic  extract  of  the  raw 
glands  of  the  sheep.  The  syphilitic  variety  calls  for  mercury  and  iodides. 
Cysts  and  malignant  neoplasms  demand  prompt  surgical  procedure. 


CHAPTER    VIII 
DISEASES    OF   THE    HEART    AND    PERICARDIUM 


CONGENITAL  DISEASES  OF  THE  HEART 

Diseases  of  the  heart  in  early  life  may  be  structural  or  functional, 
congenital  or  acquired,  acute  or  chronic.  The  vessels  are  rarely  the 
seat  of  morbid  changes,  although  injury  to  the  vessel  walls  or  infection 
may  induce  thrombosis  with  occlusion  or  septicaemia.  In  rare  instances 
arteriosclerosis  is  observed  even  in  childhood,  and  hypoplasia  is  occa- 


Fig.  140.— Congenital  malformation  at  aortic  orifice.     Stick  inserted  through  false  passage  behind 

semilunar  valve. 

sionally  seen  and  may  be  hereditary.     Narrowing  of  the  isthmus   of 
the  aorta  and  even  atresia  have  been  reported. 

Congenital  cardiac  disease  is,  in  the  large  majority  of  cases,  due  to 
malformation   of  the  heart   or   anomalous   arrangement   of   its   vessels 

19  289 


290 


DISEASES    OF    THE    HEART 


either  from  arrest  of  development  or  from  intrauterine  inflammation. 
There  may  be  a  persistence  of  fetal  conditions  as  a  result  of  either  pro- 
cess. The  causes  of  developmental  anomalies  in  the  heart  are  generally 
obscure.  In  a  few  instances  prenatal  endocarditis  has  seemed  to  follow  a 
rheumatic  infection  in  the  mother.  Again,  other  associated  anatomical 
defects,  as  spina  bifida,  anencephalia,  polydactylia,  etc.,  suggest  a  com- 
mon etiology. 

Among  the  commonest  congenital  anomalies  are  stenosis  of  the  pul- 
monary conus  or  artery,  defects  in  the  ventricular  or  auricular  septa, 
and  persistent  patency  of  the  ductus  arteriosus.     The  semilunar  valves 


1 


L— 


2f~  '  ■■■;: 


Fig.  141.— Cardiac  malformation.    Common  trunk  for  aorta  and  pulmonary  artery. 
Bristle  passed  through  foramen  ovale. 


may  be  absent  or  rudimentary,  increased  or  decreased  in  number  or 
fenestrated.  Two  or  more  valves  may  be  adherent,  greatly  narrowing  the 
orifice,  or  the  base  of  a  valve  may  be  attached  to  a  fibrinous  band 
stretched  across  a  portion  of  the  auriculoventricular  ring,  leaving  a  free 
passage  behind.  A  false  passage  may  be  formed  behind  the  base  of  a 
semilunar  valve  (Pig.  141). 

Aberrant  chordse  tending  may  cross  the  ventricle,  having  no  con- 


CONGENITAL    DISEASES    OF    THE    HEART  291 

nection  with  valves  and  columnar,  giving  rise  to  peculiar  vibrations, — 
the  so-called  musical  heart. 

The  aorta  and  pulmonary  artery  may  arise  from  a  common  trunk, 
from  one  or  other  of  the  ventricles,  or  from  both  (Fig.  l-i'2).  Either 
ventricular  or  auricular  septum  may  be  entirely  wanting,  the  heart 
being  tri-  or  bi-  or  unilocular.  The  vessels  emerging  from  the  heart  may 
be  transposed.  The  heart  itself  may  be  displaced.  It  has  been  found  in 
the  right  side  of  the  chest,  in  the  neck,  in  the  abdomen,  or  in  the  chest 
wall,  covered  only  by  the  integument. 

Congenital  heart  diseases  are  usually  confined  to  the  right  side,  while 
those  of  postnatal  origin  select  the  left.    Of  the  many  congenital  defects 


Fig.  142.— Congenital  malformation  of  the  heart.  Boy,  11  years  old.  Stenosis  of  pulmonary  conus. 
1,  malformation  of  pulmonary  valve  (2  cusps);  2,  2,  aneurysm  of  right  ventricular  wall ;  3,  acute  mural 
endocartis  ;  perforate  ventricular  septum. 

it  rarely  occurs  that  one  is  found  alone.  Thus  the  most  common,  pul- 
monary stenosis,  is  generally  accompanied  by  defect  in  the  ventricular 
septum,  by  patent  ductus  arteriosus,  foramen  ovale,  and  by  right-sided 
hypertrophy,  all  of  which  are  compensatory  to  the  obstruction  in  the 
pulmonary  outlet  (Fig.  142).  The  patency  of  the  fetal  openings  may 
also  persist  as  conpensatory  to  obstruction  in  the  circulation  of  the 
lungs,  as  in  congenital  atelectasis.  Both  pulmonary  and  tricuspid  in- 
sufficiency occasionally  occur  as  a  result  of  fetal  endocarditis. 

Symptoms. — The  principal  symptoms  of  congenital  heart  disease  are 


292  DISEASES    OF    THE    HEART 

cyanosis,  dyspnoea,  tumultuous  action  of  the  heart,  right-sided  hyper- 
trophy, loud,  widely  diffused  murmurs,  clubbed  fingers  and  toes,  and 
retarded  development.  Of  these  the  most  constant  is  cyanosis,  which  may 
be  noted  at  birth  or  appear  for  the  first  time  weeks  or  even  months  later. 
It  may  vary  in  degree  from  a  slight  blueness  of  the  lips  and  nails  to  a 
dusky  hue  of  the  entire  integument.  The  cyanosis  may  be  present 
only  during  spells  of  excitement,  crying,  or  coughing,  or  during  some 
unusual  exertion,  or  it  may  be  continuous  for  months  or  years.  There 
may  be  clubbing  of  the  terminal  phalanges  of  the  fingers  and  toes 
from  venous  stasis,  which  is  rarely  accompanied  by  oedema  of  the 
extremities. 

Cardiac  hypertrophy  may  cause  bulging  of  sternum  or  ribs  from 
pressure  during  the  plastic  period  of  infancy,  with  or  without  rhachitis. 
Growth  is  retarded,  children  who  survive  remaining  puny  and  stunted  in 
stature.  Even  slight  exertion  occasions  dyspnoea  with  tachycardia.  The 
chest  wall  vibrates  over  the  tumultuous  heart  and  occasionally  a  distinct 
thrill  is  discovered  on  palpation  of  the  praecordia.  Abnormal  heart 
sounds,  when  present,  are  usually  systolic,  loud  and  harsh  in  character, 
frequently  heard  all  over  the  chest,  but  with  greatest  intensity  in  the  pul- 
monic area.  In  the  combined  lesions  double  murmurs  are  sometimes 
present  and  the  varieties  as  to  character  and  location  may  be  extremely 
confusing.  Occasionally  no  murmur  is  heard  in  congenital  heart  dis- 
ease and  cyanosis  may  be  absent,  the  condition  being  unsuspected  until 
discovered  in  the  course  of  routine  examination,  as  shown  by  the  hyper- 
trophy and  dilatation  of  the  right  ventricle.  Congenital  heart  lesion 
may  be  suspected  from  physical  or  mental  backwardness  unexplained  by 
other  causes. 

Diagnosis.— The  diagnosis  of  congenital  from  acquired  disease  of  the 
heart  is  aided  by  a  history  of  cyanosis  (the  earlier  the  development  the 
more  probable  its  congenital  origin ) ,  the  harsh  character  of  the  murmurs 
with  their  greater  basic  intensity,  and  the  signs  of  right  cardiac  involve- 
ment. The  diagnosis  of  the  precise  nature  of  the  lesions  is  at  times 
difficult,  if  not  impossible,  from  the  confusion  of  symptoms  and  signs 
due  to  a  multiplicity  of  structural  defects. 

Prognosis. — The  prognosis  is  always  grave,  a  large  majority  dying 
in  the  first  year  and  many  in  the  first  weeks  of  life.  When  compensa- 
tion is  efficient,  life  is  occasionally  prolonged  to  mature  years.  The 
possibility  of  intercurrent  disease,  however,  in  which  the  function  of 
the  crippled  heart  would  prove  inadequate,  must  always  be  kept  in 
mind. 

Treatment. — Management  of  congenital  heart  defects  should  be  di- 
rected, first,  towards  the  conservation  of  cardiac  energy ;  second,  to  pro- 
tection from  the  dangers  of  dilatation.  The  first  requires  the  best  of  care 
as  to  nutrition,  bathing,  fresh  air,  sunshine  and  cautiously-graded  exer- 
cise. Systematic  massage  will  often  promote  the  circulation  and  lighten 
the  functional  burden  of  the  heart.  The  second  demands  the  avoidance 
of  all  conditions  that  impose  extra  work  upon  the  already  overtaxed 


FUNCTIONAL    HEART    DISEASE  2!J:J 

heart,  such  as  undue  excitement,  violent  exercise,  inflammations,  or  con- 
gestions. The  child  must  be  protected  from  sudden  chilling  of  the  sur- 
face and  from  all  infectious  disorders,  especially  those  which  cause  pul- 
monary congestions,  as  bronchitis,  measles,  and  pertussis.  The  tendency 
to  endocarditis  in  defective  hearts  should  be  remembered  and  a  rheu- 
matic diathesis  would  require  special  prophylaxis  against  inflammations 
of  that  type.  Routine  treatment  with  drugs  is  useless  and  may  be  dan- 
gerous. Attacks  of  dyspnoea  with  tachycardia  call  for  measures  to 
equalize  the  circulation.  Pressure  from  distention  of  the  abdominal  vis- 
cera must  be  relieved  by  prompt  evacuation  of  the  bowels  and  the  cor- 
rection of  gastro-enteric  disturbance.  Obstruction  to  the  blood  current 
from  pulmonary  congestion  may  require  the  derivative  action  of  rube- 
facients, heat  to  the  extremities,  etc.  Extreme  cases  of  right-heart  dis- 
tention may  demand  leeches  to  the  right  side  of  the  chest.  The  free  use 
of  bromides  will  often  allay  cardiac  excitement.  Aromatic  spirits  of 
ammonia  may  avert  threatened  syncope.  A  judicious  use  of  digitalis, 
carefully  watched,  sometimes  strengthens  the  systole  and  quiets  the 
delirium  cordis. 

FUNCTIONAL  HEART  DISEASE. 

Functional  heart  disturbance  is  a  term  applied  to  abnormal  cardiac 
signs  and  symptoms  in  the  absence  of  structural  lesions.  Strictly  speak- 
ing, it  should  be  classed  among  the  neuroses. 

Evidences  of  functional  disturbance  may  be  either  motor  (arhythmia, 
tachycardia,  bradycardia,  syncope  and  palpitation),  or  sensory  (pre- 
cordial pain  or  uneasiness,  nausea  and  vertigo). 

The  difference  of  opinion  among  authorities  as  to  the  infrequency 
of  functional  cardiac  disease  in  infancy  and  early  childhood  is  evidently 
due  to  a  misunderstanding  as  to  the  scope  of  the  disturbances  included 
under  the  term.  No  cardiac  phenomena  are  more  common  in  infancy 
than  the  variations  of  rhythm  and  frequency  from  apparently  insignifi- 
cant causes.  In  fact,  all  the  motor  manifestations  before  mentioned 
are  seen  in. infancy  and  childhood,  and  have  been  attributed  to  the  im- 
perfect co-ordination  and  undeveloped  inhibition  characteristic  of  this 
period.  It  may  be  that  the  cardiac  neuroses  of  later  life  offer  no  better 
explanation  of  their  etiology  as  they  appear  in  the  unstable  inhibition  of 
highly  neurotic  individuals.  The  sensory  phenomena  are  never  seen  in 
infancy  and  rarely  in  young  children.  Heart  consciousness,  as  it  is 
termed,  is  evidently  a  result  of  education,  and  attains  its  height  of 
clinical  perfection  in  the  hysterical  woman.  Next  to  unstable  inhibition, 
ana?mia  is  probably  the  commonest  contributing  cause.  The  exciting 
causes  may  be  limited  only  by  the  number  of  causes  of  reflex  disturbance, 
whether  mental,  emotional,  respiratory,  digestive  or  sensory.  Fatigue, 
excitement,  and  shock  are  undoubtedly  the  most  prominent  factors  in 
the  precipitation  of  an  attack,  although  the  use  of  certain  drugs,  such 
as  tea,  coffee,  tobacco  and  alcohol,  diminish  the  stability  of  the  heart's 
action. 

Perversion  of  organic  secretions,  also  pressure,  produce  well  known 


294  DISEASES    OF    THE    HEART 

symptoms  of  cardiac  disturbance,  as  the  tachycardia  of  exophthalmic 
goitre,  seen  occasionally  in  childhood.  The  syncope,  sometimes  fatal, 
from  an  enlarged  thymus,  and  the  bradycardia  of  postepileptic  coma, 
present  etiologic  features  still  open  to  discussion. 

Functional  cardiopathies  appear  in  the  form  of  recurrent  attacks, 
varying  in  duration  from  a  few  minutes  to  an  hour.  With  recurrence  of 
an  exciting  cause  the  symptoms  may  return  at  intervals  for  many  days 
or  indefinitely. 

The  child  may  show  merely  a  disturbance  of  pulse-rate  and  rhythm 
or  there  may  be  sinking  spells  with  pallor,  unconsciousness,  and  muscu- 
lar collapse.  During  these  the  heart-beat  is  feeble  and  indistinct  and 
the  respiration  is  shallow  and  irregular. 

The  diagnosis  of  functional  from  structural  disease  is  not  always  easy, 
as  the  latter  may  exhibit  all  the  symptoms  of  the  former.  The  main  points 
of  difference  in  favor  of  functional  disorder  are  the  short  duration  of  the 
attack,  the  rarity  of  persistent  venous  congestion,  the  brevity  or  ab- 
sence of  dyspnoea  and  cyanosis,  the  infrequency  of  pulmonary  engorge- 
ment and  accentuation  of  the  second  pulmonic  sound,  and  the  character 
of  the  cardiac  murmurs  when  present.  These  murmurs  are  usually  soft, 
basic,  and  transmitted  only  to  the  vessels  of  the  neck,  rather  than  harsh 
and  apical,  with  more  definite  conduction.  The  heart  rarely  shows 
the  enlargement  so  common  in  organic  disease,  although  a  dilated  left 
ventricle  with  the  systolic  murmur  of  relative  incompetency,  somewhat 
frequently  observed  in  anaemic  children,  seems  to  occupy  an  intermediate 
place  between  organic  and  functional  affections.  The  error  of  pronounc- 
ing a  heart  diseased  upon  the  discovery  of  adventitious  sounds  would 
be  less  common  if  the  accidental  murmurs  of  the  child's  heart  were  bet- 
ter understood. 

The  soft  systolic  bruit  common  to  infectious  fevers,  the  cardiores- 
piratory murmur  of  vesicular  emphysema,  and  the  before-mentioned 
sounds  due  to  anaemia  and  transient  incompetency,  are  all  encountered 
in  childhood. 

Repeated  observations  should  precede  a  positive  diagnosis  of  organic 
disease  in  a  child  suffering  from  anaemia. 

The  treatment  for  the  relief  of  an  attack  of  syncope  requires  the 
recumbent  posture  and  diffusible  stimulants, — as  camphor  by  mouth  or 
inhalation ;  whiskey,  or  aromatic  spirits  of  ammonia.  Friction  and 
warmth  to  the  extremities,  cautious  inhalation  of  ammonia  with  cold 
affusions  to  the  face  and  precordia  may  be  employed.  Tachycardia  and 
delirium  cordis  require  sedatives  and  antispasmodics,  such  as  bromides, 
valerian,  and  asafetida.  Mental  suggestion  may  be  used,  and  the  relief 
or  removal  of  any  known  exciting  cause  should  be  attempted.  Evacu- 
ation of  the  bowels  by  a  high  colonic  flushing  may  be  necessary,  and 
milk  of  asafetida  may  be  administered  per  rectum.  Heart  spasm 
(pseudoangina)  with  vasomotor  constriction  may  be  relieved  by  nitro- 
glycerin, one  one-hundredth  of  a  grain  (0.0006  Gm.)  or  the  inhalation 
of  nitrite  of  amyl. 


ACUTE    ENDOCARDITIS  295 

For  the  general  condition  cardiac  and  hajmic  tonics,  as  iron,  quinia 
and  strychnia,  are  indicated,  conjoined  with  nutritious  diet  and  improved 
hygiene,  which  should  protect  the  child  from  overwork,  worry,  or  excite- 
ment. 

ACUTE  ENDOCxYRDITIS. 

Acquired  heart  disease  is  of  common  occurrence  in  childhood,  al- 
though not  frequent  before  the  third  year.  It  is  now  generally  believed 
that  acute  endocarditis  is  always  secondary  and  due  to  some  infectious 
organism.  In  childhood,  rheumatism  is  the  etiologic  factor  in  about 
seventy-five  per  cent,  of  the  cases.  In  fact,  the  endocardial  inflamma- 
tion is  sometimes  the  first  and,  occasionally,  the  only  manifestation  of 
the  rheumatic  diathesis.  Chorea  and  angina  so  frequently  precede  or 
accompany  rheumatic  endocarditis  that  they  are  justly  regarded  as  man- 
ifestations of  a  common  infection  which  occasionally  simulates  the  adult 
type  in  the  development  of  arthritic  symptoms.  Acute  endocarditis  is 
also  a  sequel  of  other  infections,  such  as  scarlet  fever,  pneumonia,  empy- 
ema, influenza,  typhoid  fever,  measles,  diphtheria,  and  septic  bone  dis- 
ease. Most  of  the  pyogenic  bacteria,  from  the  frequent  streptococcus 
and  pneumococcus  to  the  rarer  gonococcus  and  colon  bacillus,  have  been 
found  present  in  the  excrescences  of  acute  endocarditis. 

Acute  endocarditis  almost  always  involves  the  left  side  of  the  heart, 
in  which  point  it  differs  from  endocarditis  of  prenatal  origin,  which  is 
rarely  left-sided.  Occasionally,  however,  an  acute  exacerbation  may 
develop  upon  chronic  right  heart  lesions  or  malformations.  The  inflam- 
mation is  usually  confined  to  that  portion  of  the  endothelium  covering 
the  valves,  especially  along  their  line  of  closure,  although  it  sometimes 
extends  to  other  portions  of  the  ventricular  lining.  In  an  overwhelming 
majority  of  cases  the  mitral  valve  is  the  one  involved,  the  aortic  being 
far  less  frequently  affected. 

In  an  acute  attack  the  endothelium  covering  the  valves  becomes  con- 
gested, loses  its  lustre,  and  the  valve  becomes  thickened  and  cedematous. 
Areas  of  hyperplasia  develop  in  the  subendothelial  structures  in  cir- 
cumscribed elevations  or  verruccas.  Endothelial  hyperplasia  and  partly 
organized  exudate  may  give  rise  to  fungiform  excrescences  which,  be- 
coming detached  by  the  blood  stream,  lodge  in  distant  organs,  as  the 
spleen,  brain,  kidneys,  and  lungs.  If  infected,  these  emboli  may  cause 
multiple  abscesses.  Erosion  of  the  soft  epithelium  results  in  ulceration 
(ulcerative  endocarditis).  In  severe  endocarditis,  the  myocardium  is 
usually  affected  to  a  greater  or  less  degree  and  acute  dilatation  is  an 
ever-threatened  danger,  with  its  weakened  systole  and  disturbance  of 
valvular  coaptation.  Distortion  of  the  valves,  by  the  later  shortening 
and  thickening  of  their  free  borders,  further  interferes  with  their  coapta- 
tion, while  adherence  at  their  points  of  junction  may  diminish  the  lumen 
of  the  opening,  so  that  obstruction  as  well  as  valvular  insufficiency  may 
result.  Inflammatory  softening  and  ulceration  of  the  endocardium  may 
lead  to  perforation  of  the  valve. 

Symptoms. — The  onset  of  an  acute  endocarditis,   developing  inde- 


296  DISEASES    OF    THE    HEART 

pendently  of  other  disorders,  presents  the  general  symptoms  of  an  acute 
infection,  snch  as  malaise,  fever,  possibly  nausea  or  vomiting,  anorexia, 
irritability,  restlessness,  or  stupor,  with  rapid  and  sometimes  irregular 
pulse  and  dyspnoea,  with  or  without  cyanosis.  Young  children  rarely 
complain  of  palpitation  or  the  precordial  pain  frequently  seen  in  adults. 
The  true  nature  of  the  disturbance  is  often  overlooked,  especially  if  ac- 
companied by  pharyngitis,  tonsillitis,  indigestion  or  during  the  preva- 
lence of  influenza,  the  febrile  symptoms  being  usually  attributed  to  those 
disorders.  A  routine  examination  of  the  heart,  however,  will  prevent 
such  errors  in  diagnosis.  In  the  first  day  of  a  mild  attack  tachycardia 
and  arhythmia  may  be  the  only  evidence  of  cardiac  involvement.  Usually 
by  the  second  or  third  clay  a  soft  systolic  bruit  is  heard  most  distinctly 
at  the  apex  and  transmitted  to  the  left.  The  heart  may  be  seen  to  pulsate 
violently  through  the  thin  chest  wall  and  the  delirium  cordis  is  occa- 
sionally accompanied  by  a  thrill.  Sometimes  as  early  as  the  second  or 
third  day  the  area  of  cardiac  dulness  is  extended  to  the  left,  the  apex 
beat  lying  without  the  nipple  line.  Daily  examinations  may  show  in- 
creasing intensity  of  the  systolic  murmur,  diffuseness  of  the  apex  beat 
and  greater  dilatatiom  Dyspnoea,  dry  cough,  cyanosis,  and  accentuated 
second  pulmonic  sound  indicate  increased  labor  of  the  right  heart  and 
pulmonary  congestion  from  inefficiency  of  the  weakened  left  heart.  As 
the  disease  progresses  occasionally  a  systolic  murmur,  developing  at  the 
base  and  transmitted  towards  the  neck,  shows  involvement  of  the  aortic- 
valves.     In  rare  instances  this  region  is  primarily  affected. 

In  the  majority  of  first  attacks  of  acute  endocarditis  the  symptoms 
may  gradually  subside  in  from  two  to  four  weeks,  leaving  a  more  or 
less  dilated  left  ventricle,  some  thickening  of  the  affected  valves,  and 
persistent  murmurs  indicative  of  incompetency  or  stenosis.  Rarely  the 
heart  appears  to  recover  entirely,  leaving  no  indication  of  the  inflam- 
matory process. 

The  terms  malignant,  infectious,  and  ulcerative  endocarditis  have 
been  applied  to  attacks  in  which  the  virulence  of  the  infecting  organism 
leads  to  extensive  destruction  of  the  endothelium  or  subjacent  valvular 
tissues,  and  to  the  development  of  abscesses  from  infective  emboli  in 
other  organs  of  the  body.  This  form  is  rare  in  early  childhood.  It 
most  frequently  develops  on  the  site  of  lesions  which  have  resulted  from 
repeated  attacks  of  simple  endocarditis.  Malignant  endocarditis  may 
occur  as  a  terminal  affection  in  children  with  congenital  heart  defects. 
It  rarely  occurs  in  a  previously  sound  heart  and  is  most  often  met  with 
as  a  complication  of  general  septic  and  toxic  disorders.  The  clinical 
picture  is  one  of  severe  sepsis  with  its  intermittent  temperature,  pro- 
fuse sweats  with  or  without  rigors,  hepatic  and  splenic  enlargement,  and 
profound  prostration.  There  is  usually  a  cardiac  murmur  correspond- 
ing to  the  valve  affected,  although  this  sign  may  be  due  to  an  old  lesion. 
The  pulse  is  extremely  arhythmic.  There  is  general  ataxia,  accompanied 
by  delirium  or  stupor.  There  may  be  vomiting  and  diarrhoea  and  later 
hsematuria,  epistaxis  and  petechia?.    Hemiplegia  from  cerebral  embolism 


ACUTE    ENDOCARDITIS  297 

may  develop  and  simulate  meningitis.  The  cough  may  produce  sputum 
containing  pus  from  abscesses  in  the  lungs.  Sudden  pain  in  the  left 
hypochondrium  may  follow  septic  infarcts  in  the  spleen. 

Diagnosis. — The  diagnosis  of  acute  endocarditis  should  be  based  upon 
the  increased  area  of  cardiac  dulness,  rapid  and  arhythmic  pulse,  pre- 
cordial distress,  dyspnoea,  and  adventitious  sounds.  An  endocardial 
murmur  differs  from  the  friction  rub  of  pericarditis  which  is  heard  with 
both  sounds  of  the  heart,  also  from  the  accidental  bruits  which  are  heard 
usually  at  the  base. 

Malignant  endocarditis  may  be  diagnosed  from  meningitis  by  evi- 
dence of  cardiac  involvement,  history  of  previous  endocardial  attacks, 
and  the  occurrence  of  multiple  septic  processes.  From  malaria,  whose 
temperature,  sweats,  and  splenic  enlargement  it  may  simulate,  it  may  be 
differentiated  by  the  presence  of  cardiac  symptoms  and  absence  of 
Plasmodia  in  the  blood  and  reaction  to  quinine.  Typhoid  fever  shows  a 
more  gradual  onset,  and  the  presence  of  the  Widal  reaction.  From 
uncomplicated  pneumonia  it  is  diagnosed  by  the  temperature  curve  and 
physical  signs.  The  leucocytosis  of  malignant  endocarditis  will  aid  in 
the  diagnosis  from  typhoid  and  malarial  fevers. 

Prognosis. — The  prognosis  in  simple  acute  endocarditis  is  good  so  far 
as  life  is  concerned,  since  children  very  rarely  die  in  the  first  attack. 
A  predisposition  to  subsequent  attacks  is  among  the  sequelae,  the  most 
common  of  which  is  chronic  endocarditis.  The  prognosis  in  malignant 
endocarditis  is  extremely  grave.  Rare  recoveries  have  been  reported, 
although  with  permanently  disabled  hearts. 

Treatment. — The  main  points  in  the  treatment  of  acute  simple  endo- 
carditis are  to  reduce  the  work  of  the  heart  to  the  minimum,  to  allay 
cardiac  excitement,  and  to  maintain  free  elimination.  Upon  the  first 
suspicion  of  endocarditis  the  child  should  be  put  to  bed  and  given  a 
purgative.  A  small  bag  of  ice  or  the  Leiter  coil  over  the  precordia  will 
quiet  the  heart's  action  without  impairment  of  its  tone.  Even  young 
children  may  be  accustomed  to  the  cold  if  the  application  be  made  grad- 
ually, layers  of  flannel  being  at  first  interposed  between  the  ice-bag  and 
the  chest.  Sleep,  however,  induced,  is  the  most  favorable  condition  for 
cardiac  tranquillity.  Bromide  of  sodium,  from  one  to  ten  grains  (0.065- 
0.65  Gm.)  in  syrup  of  lactucarium,  may  be  given  every  two  hours  if 
necessary.  Pain  and  restlessness,  if  persistent,  may  best  be  met  with 
opium,  if  the  above-mentioned  measures  fail.  Morphine,  hypodermically, 
is  the  most  satisfactory  form  of  administration.  The  dose  must  be 
carefully  gauged  by  the  requirements  of  the  case,  the  age  of  the  child, 
and  the  possibility  of  idiosyncrasy.  Dover's  powder,  one-half  to  two 
grains  (0.03-0.13  Gm.)  may  be  given  by  mouth,  if  the  use  of  the  needle 
excites  the  child.  A  frequent  repetition  of  the  opiate  is  rarely  neces- 
sary, as  the  effects  of  one  dose  may  continue  for  hours. 

The  food  should  be  liquid,  easily  digested,  and  reduced  in  quantity 
to  avoid  the  possibility  of  heart  embarrassment  from  pressure  of  dis- 
tended stomach  and  bowels. 


298  DISEASES    OF    THE    HEART 

The  possibility  of  rheumatism  should  be  kept  in  mind  as  the  most 
frequent  cause  of  heart  disease  in  childhood.  Rheumatism  should  be 
combated  by  the  free  administration  of  salicylates  and  alkalies.  Digi- 
talis, strychnia,  and  other  cardiac  stimulants,  are  generally  held  to  be 
harmful  in  acute  endocarditis.  The  routine  administration  of  aconite, 
veratrum,  and  the  coal-tar  products  which  depress  the  heart,  should  be 
condemned.  In  advanced  stages  of  the  disease,  where  the  heart's  action 
is  weak  and  anaemia  develops,  the  ice  should  be  removed  and  warm  appli- 
cations made  over  the  precordia.  In  threatened  syncope  aromatic  spirits 
of  ammonia  or  alcoholic  stimulants  may  be  given  and  normal  salt 
solution  should  be  employed  by  enteroclysis  or  subcutaneously. 

Daily  examinations  of  the  heart  should  be  made  to  determine  the 
extent  of  right-heart  embarrassment,  resultant  from  the  enfeebled  left 
heart.  The  application  of  leeches  to  the  right  hypochondrium  should  not 
be  postponed  when  the  right  auricle  shows  persistent  dilatation  of  two 
finger-breadths  in  the  fourth  right  interspace. 

The  child  should  be  kept  in  bed  for  several  weeks  after  the  sub- 
sidence of  all  acute  symptoms,  as  incalculable  damage  to  the  crippled 
valves  and  weakened  myocardium  may  follow  early  heart-strain.  Good 
ventilation  and  carefully  regulated  nutritious  diet  should  be  supple- 
mented by  iron,  quinia,  and  strychnia,  in  view  of  the  anaemia  and  mus- 
cular atony. 

The  tendency  to  recurrent  attacks  of  endocarditis  should  never  be 
forgotten.  Against  this  a  prophylactic  regimen  should  be  adopted. 
Woollen  clothing  should  be  worn  summer  and  winter,  the  weight  adapted 
to  the  season.  The  child  should  be  accustomed  to  the  daily  cool  bath. 
His  diet  should  never  lack  a  free  supply  of  alkalies,  vegetables,  and  fruit 
juices.  Violent  athletics  or  prolonged  tests  of  endurance  should  be  pro- 
hibited for  the  child  who  has  suffered  from  endocarditis. 

Malignant  endocarditis,  in  addition  to  the  above  treatment,  will  re- 
quire early  a  more  pronounced  support  and  stimulation.  Alcohol,  am- 
monia, quinia,  and  strychnia  should  be  freely  administered.  The  pri- 
mary focus  of  infection  should  be  sought  and  treated  secundum  artem. 
The  patient  should  be  removed  from  contaminated  air  and  unhygienic 
surroundings. 

CHRONIC    ENDOCARDITIS — CHRONIC   VALVULAR    DISEASE. 

In  childhood  chronic  valvular  disease  is  the  common  sequel  of  acute 
endocarditis.  Although  the  valves  may  appear  to  escape  permanent 
injury  from  one  attack  of  acute  inflammation,  it  is  exceptional  that  a 
second  attack  leaves  the  valve  unchanged.  Many  causes  which  operate  to 
produce  chronic  valvular  lesions  in  the  adult,  such  as  arteriosclerosis, 
gout,  syphilis,  and  alcoholism,  are  absent  or  extremely  rare  in  childhood. 
The  susceptibility  of  the  valves  to  rheumatic  poison — occasionally  the 
only  expression  of  rheumatism — is  much  greater  in  the  child. 

The  changes  most  commonly  observed  in  childhood  are  those  of  form 
and  consistency   due  to  the   growth  of  adventitious  tissue   or   to  the 


CHRONIC    ENDOCARDITIS  299 

consolidation  and  contraction  of  inflammatory  exudate.  The  valves  may 
be  unequally  shortened  or  thickened,  or  their  free  borders  deformed  by 
papillary  excrescences  so  that  perfect  coaptation  is  no  longer  possible, 
rendering  them  incompetent.  Fenestration  of  the  valve  leaflets  from  per- 
forating ulcers  may  add  to  their  insufficiency.  Two  leaflets  may  become 
agglutinated,  or  increasing  fibrosis  may  diminish  the  lumen  of  the  val- 
vular ring  so  as  to  obstruct  the  free  flow  of  blood.  The  chordae  tendinae 
may  be  thickened  and  shortened.  Deposition  of  lime  salts  may  occur, 
stiffening  the  valves  and  increasing  the  stenosis  of  the  orifice.  The  auric- 
ulo-ventricular  valve  is  the  commonest  seat  of  disease  on  account  of  its 
vascularity,  the  semilunar  valves  having  no  vessels  within  their  sub- 
stance. 

Other  causes  of  valvular  incompetency  may  be  seen  in  acute  dilata- 
tions from  heart-strain,  where  the  valves  themselves  are  not  altered 
except  in  their  relationship  to  the  enlarged  ring.  Valvular  sclerosis 
without  previous  acute  inflammation  may  be  favored  by  this  accidental 
condition,  so  that  permanent  organic  deformity  may  result.  Chronic 
valvular  disease  is  occasionally  discovered  in  children  giving  no  history 
of  acute  endocarditis,  rheumatism,  chorea,  or  exanthems,  but  who  have 
a  history  of  family  heart  disease,  so  that  a  hereditary  type  must  be 
recognized. 

Any  or  all  of  the  valves  may  be  subject  to  sclerotic  changes.  Those 
occurring  on  the  right  side  are  a  result  of  congenital  lesions,  or  may 
be  due  secondarily  to  left  heart  disease.  The  mitral  valve  is  the  seat  of 
chronic  lesions  in  childhood  in  nienty  per  cent,  of  cases.  Of  these,  in- 
competency is  the  most  common  lesion,  exceeding  stenosis  more  than  eight 
to  one.  Next  in  order  of  frequency  are  aortic  lesions,  in  which  the 
relative  frequency  of  incompetency  and  stenosis  is  still  a  mooted  question. 
The  combination  of  mitral  insufficiency  and  aortic  lesion  is  not  uncom- 
mon. The  right  heart  may  duplicate  the  lesions  of  the  corresponding 
valves  of  the  left,  although  tricuspid  stenosis  and  pulmonary  insuffi- 
ciency, as  acquired  lesions,  are  practically  unknown  in  childhood.  Sooner 
or  later  secondary  changes  inevitably  follow  crippling  of  the  valves.  Of 
these,  dilatation  from  increased  blood  pressure  is  an  early  result.  This 
is  usually  more  pronounced  in  the  auricle.  Hypertrophy  of  the  heart 
muscle,  which  is  regarded  as  compensatory,  gradually  develops  as  a  result 
of  the  increased  work.  In  long-continued  disease  hypertrophy  may  yield 
to  a  secondary  dilatation.  This  is  apt  to  follow  any  acute  illness,  espe- 
cially rheumatism. 

Symptoms. — Mild  valvular  defects,  with  good  compensation,  may 
exist  for  years  with  few  or  no  symptoms.  The  symptoms  of  more  marked 
deformities  are  those  due  to  pulmonary  congestion,  such  as  cough,  dysp- 
noea and  cyanosis,  induced  by  violent  or  even  moderate  exertion.  There 
may  be  epistaxis,  vertigo,  headache,  and  fainting.  Rarely  older  chil- 
dren complain  of  palpitation  or  precordial  distress.  In  extreme  eases 
with  right-heart  incompetency  there  may  be  orthopncea  with  superficial 
venous  congestion  and  clubbing  of  fingers  and  toes,  oedema  beginning  in 


300 


DISEASES    OF    THE    HEART 


the  feet  and  becoming  general,  enlargement  of  the  liver  and  spleen, 
albuminuria  from  renal  congestion,  anaemia,  digestive  disturbances,  and 
retarded  growth.  The  commonest  sign  is  an  increased  area  of  cardiac 
dulness  which  may  extend  to  the  left  even  as  far  as  the  axillary  line, 
and  downward  to  the  sixth  interspace,  at  the  same  time  the  right  border 
of  the  heart  may  be  outlined  two  or  three  finger-breadths  to  the  right  of 
the  sternum.  Dulness  may  appear  as  high  as  the  second  interspace. 
Instances  of  such  enormous  cardiac  enlargement,  however,  are  not  com- 
mon and  indicate  the  involvement  of  all  the  cardiac  chambers.  Hyper- 
trophy of  the  left  ventricle  is  indicated  by  increased  dulness  extending 
downwards  and  to  the  left,  with  well  defined  apex  beat  and  firm,  distinct 
systolic  impact  against  the  chest  wall.    Dilatation  also  shows  cardiac  en- 


Fig.  143.— Chronic  valvular  heart  disease,  with  dilatation  and  orthopncea. 


largement,  but  the  apex  beat  is  diffuse,  the  impact  less  distinct,  and  if 
the  chest  wall  be  thin  the  systolic  movements  appear  on  its  surface  in 
wave-like  undulations. 

Diagnosis. — In  the  diagnosis  of  chronic -valvular  disease  it  should  be 
remembered  that  so-called  haemic  or  accidental  murmurs,  although  oc- 
casionally discovered,  are  less  frequent  in  early  childhood  than  in  adult 
life ;  that  in  children  between  the  ages  of  six  and  fourteen  years  the  loud 
bruit  of  mitral  incompetency  is  frequently  due  to  acute  dilatation  of  the 
ventricle  without  disease  of  the  valve,  and  that  the  murmurs  of  organic 
lesions  are  usually  more  intense,  heard  over  larger  areas  of  the  chest 
and  are  associated  with  cardiac  enlargement. 

The  differentiation  between  the  separate  or  combined  valvular  lesions 
is  made  from  the  same  signs  that  obtain  in  valvular  disease  in  adult 
life. 

The  failure  of  compensation  may  be  attended  by  symptoms  which 


CHRONIC    ENDOCARDITIS  301 

suggest  the  gravity  of  the  condition.  The  heart's  action  becomes  rapid, 
tumultuous,  and  arhythmic,  and  the  area  of  cardiac  dulness  may  be 
noticeably  increased.  The  murmurs  may  change  in  character  or  disap- 
pear entirely.  The  pulse  is  weak,  compressible,  irregular,  or  intermittent, 
while  the  face  may  show  pallor  or  cyanosis.  The  jugulars,  particularly 
the  right,  may  be  seen  to  pulsate.  Breathing  is  hurried.  There  is  usu- 
ally cough  and  the  child  shows  evidence  of  weakness  or  prostration. 
Effects  upon  the  circulation  may  appear  in  oedema  of  the  extremities, 
hepatic  enlargement,  ascites,  and  passive  renal  congestion  with  scanty 
urine  containing  albumin  and  casts.  When  death  occurs,  the  heart  is 
arrested  in  diastole. 

Prognosis. — The  prognosis  in  chronic  valvular  disease  depends  upon 
the  degree  of  compensation  and  the  probability  of  its  maintenance.  The 
common  mitral  insufficiency  and  the  rare  aortic  stenosis  afford  the  most 
favorable  prognosis,  since  they  are  usually  wrell  compensated  in  hyper- 
trophy of  the  left  ventricle.  About  puberty  the  normal  increase  in  the 
heart  muscle  and  enlargement  of  the  aorta  still  further  lessen  the  em- 
barrassment of  the  circulation,  so  that  if  this  period  be  reached  before 
secondary  dilatation  occurs,  the  outlook  may  be  quite  favorable.  Mitral 
stenosis  gives  little  promise  of  improvement,  since  the  normal  physiolog- 
ical congestion  of  the  lungs  in  childhood  is  intensified  by  this  lesion  more 
than  by  any  other,  and  secondary  dilatation  of  the  right  heart  quickly 
follows.  In  this  lesion,  especially,  the  probabilities  of  serious  pulmonary 
disorders  must  be  reckoned  with  and  the  possibility  of  emboli  from  the 
diseased  valve  must  be  remembered.  Anaemia,  with  its  pathologic  conse- 
quences, is  one  of  the  common  results  of  chronic  valvular  disease.  A 
crippled  heart  renders  grave  anv  or  all  of  the  acute  disorders  of  earlv 
life. 

The  rare  aortic  regurgitation  is  almost  always  accompanied  by  great 
compensatory  hypertrophy  of  the  left  ventricle.*  Compensation  may  con- 
tinue for  years,  although  a  water-hammer  pulse,  throbbing  carotids,  at- 
tacks of  vertigo,  faintness,  and  even  pulmonary  congestion  from  second- 
ary lesions  of  the  mitral  valve,  may  be  present.  In  no  other  valvular 
lesion  is  danger  of  sudden  death  so  imminent  as  in  aortic  insufficiency. 
When  compensation  fails,  any  unusual  afflux  of  blood  may  arrest  the 
heart's  action  in  diastole  from  overdistention  of  the  exhausted  left  ven- 
tricle. Tricuspid  incompetency,  with  throbbing  jugulars,  dilated  right 
auricle  and  general  venous  stasis,  as  a  heritage  of  left-heart  lesions, 
heralds  the  approach  of  terminal  symptoms. 

The  rarity  of  organic  lesions  in  the  liver  and  kidneys  and  of  degen- 
erative changes  in  the  heart  and  vascular  system,  the  recuperative 
energy  of  the  developing  period,  the  developmental  changes  in  the  rela- 
tive capacity  of  the  heart,  aorta,  and  pulmonary  vessels,  all  tend  to 


*  In  this  lesion  the  area  of  cardiac  dulness  is  increased  downward,  the  apex 
reaching  at  times  as  low  as  the  eighth  rib,  while  in  mitral  incompetency  the  apex 
migrates  to  the  left. 


302  DISEASES    OF    THE    HEART 

render  more  favorable  the  prognosis  of  chronic  valvular  lesions  in  child- 
hood, despite  the  gamut  of  acute  infectious  diseases  which  the  crippled 
heart  must  run. 

Treatment. — The  management  of  chronic  valvular  disease  can  be  dic- 
tated by  no  hard  and  fast  rules,  as  it  must  depend  upon  the  peculiarities 
of  each  case.  During  adequate  compensation  no  treatment  of  the  disease 
itself  is  indicated.  A  careful  supervision  of  the  child's  hygiene  is 
necessary,  as  errors  in  diet,  excessive  exercise,  or  exposure  to  cold  or 
infection,  may  interfere  with  the  equilibrium  of  the  circulation  and 
precipitate  an  attack  of  endo-  or  pericardial  inflammation,  or  induce 
acute  dilatation.  Since  the  tendency  of  cardiac  disease  is  to  anaemia,  the 
diet  should  receive  strict  attention,  not  only  as  to  its  nutritive  value,  but 
as  to  its  digestibility,  as  indigestion  with  its  intoxications  and  pressure- 
effects  from  flatulent  distention  is  especially  likely  to  increase  the  diffi- 
culties of  the  heart. 

Excessive  ingestion  of  fluids  may  suddenly  increase  the  volume  of 
blood  to  the  detriment  of  the  heart's  action.  The  use  of  stimulants 
(tea,  coffee,  alcohol),  or  effervescing  drinks  (as  soda,  pop,  and  charged 
waters),  should  be  interdicted  for  obvious  reasons.  Especial  care  is  nec- 
essary against  exposure  to  contagious  diseases  and  pulmonary  disorders 
on  account  of  the  inflammatory  and  congestive  conditions  they  impose 
upon  the  heart's  precarious  compensation.  For  the  same  reason  all 
occupations  and  amusements  must  be  devoid  of  the  possibility  of  heart- 
strain,  from  overexertion,  fatigue,  or  excitement.  When  compensation 
is  threatened  from  any  cause,  much  may  be  done  to  preserve  it,  not  only 
by  attention  to  the  above-mentioned  rules,  but  by  the  employment  of 
certain  remedies.  The  child  should  be  kept  in  bed  to  reduce  the  neces- 
sary work  of  the  heart  to  the  minimum.  Sedatives  may  be  necessary  to 
allay  excitement  and  secure  sleep.  Bromide  of  sodium  or  potassium,  and 
even  opiates,  may  be  indicated.  Free  catharsis  by  calomel  and  soda, 
followed  by  salines,  will  diminish  renal  and  portal  congestion  and  remove 
toxic  irritation. 

Of  the  many  drugs  which  act  directly  upon  the  heart,  digitalis  un- 
questionably heads  the  list  in  failing  compensation.  This  is  especially 
true  in  the  chronic  valvular  disorders  of  childhood,  since  at  this  period 
there  is  rarely  renal,  hepatic,  or  arterial  sclerosis,  which  frequently  con- 
traindieates  the  use  of  this  drug  in  adult  life. 

The  rarity  of  aortic  lesions  still  further  reduces  the  objections  to 
the  use  of  digitalis.  "When  the  pulse  is  rapid,  irregular,  and  weak,  the 
tincture  of  digitalis,  unless  contraindicated,  may  be  given  three  to  five 
times  in  twenty- four  hours,  in  doses  of  from  one  to  eight  minims  (0.06- 
0.5  C.c.)  according  to  the  age  of  the  child  and  the  effect  upon  the  cir- 
culation. The  object  is  to  lengthen  the  diastole,  give  rest  to  the  heart 
muscle  and  strengthen  the  systole.  If  the  increased  arterial  tension 
from  the  action  of  digitalis  embarrass  the  heart,  this  may  be  relieved 
by  the  addition  of  nitroglycerin,  one  two-hundredth  to  one  one-hun- 
dredth grain  (0.0003-0.0006  Gm.).    If  the  stomach  is  intolerant  of  even 


MYOCARDITIS  303 

fat-free  digitalis  administered  in  iee- water,  the  tincture  of  strophanthus 
may  be  substituted  in  corresponding  doses.  When  avoidable,  the  use  of 
digitalis  should  not  be  continued  for  long  periods.  Intermittency  of  the 
pulse,  developing  under  its  use,  is  a  signal  for  its  withdrawal,  or  for  the 
substitution  of  some  other  agent.  In  many  instances,  however,  digitalis 
is  not  only  well  borne  but  required  for  periods  of  many  weeks  or  months. 
Strychnia  is  invaluable  as  a  heart  supporter  and  should  be  given  from 
four  to  six  times  in  the  twenty-four  hours,  preferably  by  hypodermic 
injection  in  doses  ranging  from  one  five-hundredth  to  one-fortieth  of  a 
grain  (0.00012-0.0015  Gm.).  The  alleged  idiosyncrasy  against  this  drug 
in  children  is  less  frequently  noted  than  formerly.  In  extreme  cases  it 
should  be  pushed  to  its  physiologic  limit,  with  intervals  of  three  or  four 
hours  between  doses.  Caffeine  citrate,  alone,  but  preferably  in  com- 
bination with  one  or  all  of  the  before-mentioned  drugs,  is  a  valuable 
cardiac  stimulant  in  doses  of  one-twentieth  to  one  grain  (0.003-0.065 
Gm.). 

To  tide  over  crises,  alcohol  and  aromatic  spirits  of  ammonia  may  be 
needed.  Dropsy,  from  failure  of  compensation,  wTill  require  depletion 
by  diuretics,  such  as  potassium  acetate  and  citrate,  infusion  of  digitalis, 
diuretin,  one  to  five  grains  (0.065-0.32  Gm.)  or  by  free  hydragogue 
catharsis,  compound  jalap  powder,  one  to  ten  grains  (0.065-0.65  Gm.), 
or  by  calomel  and  salines.  It  may  be  necessary  to  relieve  the  local  oedema 
by  punctures  and  scarifications  and  the  ascites  by  aspiration. 

Dyspnoea,  cough,  and  restlessness  that  do  not  improve  under  heart 
stimulation,  may  require  small  doses  of  atropine  and  codeine,  to  which, 
for  sleeplessness,  bromides  of  sodium  or  ammonium  may  be  added. 

The  necessity  for  absolute  rest  in  bed  and  freedom  from  excitement 
during  the  occurrence  of  acute  ailments,  however  trifling,  cannot  be  too 
strongly  emphasized.  There  must  be  constant  supervision,  not  only  dur- 
ing the  acute  exacerbations  but  during  convalescence,  and  in  fact 
throughout  childhood. 

MYOCARDITIS. 

Under  the  term  myocarditis  may  be  included,  for  clinical  purposes, 
any  condition  or  process  which  affects  the  integrity  of  the  heart  muscle. 
The  question  as  to  whether  such  changes  be  inflammatory  or  degenera- 
tive, parenchymatous  or  interstitial,  circumscribed  or  diffuse,  is  usually 
determined  at  the  autopsy.  Primary  myocarditis  is  probably  rare  in 
infancy  and  childhood,  although  sufficiently  common  as  a  fetal  lesion. 

Acute  dilatation  of  the  left  ventricle  in  the  course  of  infectious  dis- 
eases, as  diphtheria,  scarlet  and  typhoid  fevers,  and  also  during  attacks 
of  endo-  and  pericarditis,  has  long  been  recognized  as  a  grave  complica- 
tion or  sequel.  The  frequent  increase  in  the  area  of  cardiac  dulness 
with  the  signs  of  developing  relative  mitral  insufficiency  in  acute  febrile 
disorders,  confirms  the  growing  belief  that  the  heart  muscle  rarely  escapes 
the  deteriorating  effects  of  the  systemic  invasion  of  pathogenic  bacteria 
or  their  toxins.    That  the  left  ventricle  should  be  the  most  frequent  seat 


304  DISEASES    OF    THE    HEART 

of  these  inflammatory  or  degenerative  lesions  is  due  to  its  greater  activ- 
ity. Occasionally  the  right  heart  first  yields,  as  in  pertussis  and  pneu- 
monia, emphasizing  this  same  principle. 

Post-mortems  show  the  heart  to  be  pale,  flabby,  and  usually  enlarged. 
It  may  present  mottled  areas  of  gray  or  yellow,  interspersed  with  pale 
or  normal  tissue.  Whitish  streaks  or  fibrinous  plaques  appear  beneath 
the  endo-  or  pericardium,  also  islands  of  hypertrophied  tissue  are  seen 
squeezed  forward  by  surrounding  zones  of  contracting  fibrosis,  pro- 
ducing a  polypoid  effect  upon  the  cardiac  intima.  Yielding  portions  of 
the  myocardium  may  result  in  aneurysms.  There  may  be  fatty,  granular, 
or  hyaline  degeneration  of  the  muscle  fibre,  minute  multiple  abscesses  in 
the  heart  wall,  thrombi  in  the  smaller  vessels,  and  sclerotic  areas  of 
varying  size  with  cicatrization. 

Symptoms. — The  signs  and  symptoms  of  myocarditis  bear  no  relation 
to  the  character  or  extent  of  the  changes  in  the  myocardium.  Unfor- 
tunately, there  are  no  pathognomonic  symptoms  of  this  grave  condition. 
In  all  acute  infections,  during  prolonged  fevers  and  in  endo-  and  peri- 
cardial inflammations,  involvement  of  the  myocardium  should  always  be 
suspected  when  the  pulse  becomes  weak,  thready,  slow,  irregular,  or 
intermittent.  The  disturbance  of  rhythm  first  approaches  the  fetal 
type ;  later,  remissions  occur  in  the  force  of  the  systole,  with  indistinct- 
ness of  the  apex  beat.  Careful  percussion  may  show  increased  area  of 
dulness  extending  downward  and  to  the  left,  indicative  of  dilatation. 
In  this  case  a  systolic  murmur  from  a  relative  insufficiency  may  first  be 
heard.  Dulness,  also,  may  extend  two  or  three  finger-breadths  to  the 
right  of  the  sternum  in  obstructive  disorders  of  the  respiratory  tract, 
or  as  secondary  to  dilatation  of  the  left  ventricle.  Right  myocarditis 
invariably  produces  enlargement  of  the  liver  and  spleen  and  venous 
engorgement  of  the  abdominal  viscera.  Dyspnoea  on  slight  exertion,  with 
pallor  of  the  face,  is  an  early  evidence  of  left  myocardial  insufficiency. 
Subsequent  cyanosis  indicates  extension  to  the  right  heart. 

Whether  a  condition  frequently  observed  in  acute  infections,  espe- 
cially rheumatic,  in  which  there  is  early  increase  in  the  area  of  cardiac 
dulness,  occasionally  accompanied  by  a  soft  systolic  bruit,  may  be  myo- 
carditis is  an  interesting  question,  since  the  disappearance  of  these 
signs  with  the  recession  of  the  infection  and  the  absence  of  cardiac 
sequehe  are  suggestive  of  a  spontaneous  cure.  The  dilated  or  "  weak 
heart"  so  frequently  encountered  :'n  convalescence  from  severe  acute 
disease,  as  typhoid  and  scarlet  fevers,  and  especially  diphtheria,  is  no 
doubt  frequently  due  to  changes  m  the  myocardial  structure,  more  ex- 
tensive than  those  which  constitute  the  general  myasthenia.  The  func- 
tional activity  of  the  heart,  as  compared  with  that  of  the  voluntary 
muscles,  may  furnish  a  reason  for  its  greater  susceptibility  to  bacterial 
intoxication. 

Prognosis. — The  immediate  prognosis  is  more  favorable  in  children, 
on  account  of  the  absence  of  vascular  and  organic  sclerosis,  than  in 
adult  life.     Acute  nephritis  following  scarlet  fever  may  prove  a  deter- 


PERICARDITIS  305 

mining  factor  in  an  unfavorable  outcome  of  the  myocarditis.  The  prog- 
nosis of  a  myocarditis  which  results  in  extensive  parenchymatous  and 
interstitial  changes  in  the  heart  muscle  must  necessarily  be  grave, 
although  with  care  the  unimpaired  muscular  fibres  may  serve  to  main- 
tain moderate  functional  requirements  for  an  indefinite  period.  A  case 
is  recently  reported  of  heart  rupture  in  a  young  infant  from  multiple 
abscesses  in  the  myocardium.  However,  with  the  difficulties  attending 
the  diagnosis  of  myocarditis,  who  shall  deny  that  many  cases  result  in 
complete  recovery? 

Treatment. — The  treatment  must  apply  in  the  majority  of  cases  to 
a  suspected  condition.  It  is  essentially  prophylactic  against  acute  dila- 
tation with  its  resultant  incompetency.  Prevention  of  intoxication  should 
be  attempted  by  the  early  use  of  known  specific  agents,  such  as  antitoxin 
in  diphtheria,  salicylates  and  alkalies  in  rheumatism,  and  the  ice-bag  in 
endo-  and  pericarditis. 

The  details  for  treatment  are  the  same  as  for  endocardial  inflamma- 
tion with  which  the  myocarditis  is  so  frequently  associated.  Special 
care  should  be  directed  to  keeping  the  patient  recumbent  long  after  the 
subsidence  of  all  acute  symptoms.  It  is  better  to  keep  the  child  in  bed 
for  many  weeks  than  to  subject  the  weakened  heart  to  undue  strain  with 
the  possibility  of  sudden  arrest  or  permanent  disablement.  The  demands 
upon  this  organ  should  be  minimized  by  every  known  means.  Violent 
purgation  should  be  avoided  and  emesis  prevented.  A  free  supply  of 
oxygen  must  be  insured  and  the  cylinder  at  the  bedside  may  be  necessary. 

ACUTE   PERICARDITIS. 

Acute  pericarditis  is  not  often  seen  before  the  third  year,  although 
it  is  occasionally  found  in  early  infancy  and  may  develop  in  utero.  It 
is  frequently  met  with  after  the  third  year  and  is  one  of  the  most 
common  fatal  complications  of  rheumatism.  It  is  rarely  if  ever  primary, 
and  is  undoubtedly  due  to  infection  by  one  or  more  of  a  variety  of 
pyogenic  organisms.  After  rheumatism,  it  is  encountered  most  fre- 
quently in  pleurisy,  pneumonia,  the  acute  exanthems  (especially  scarlet 
fever),  tuberculosis,  and  pya?mia.  It  is  seldom  found  alone,  but  is 
usually  accompanied  by  myocarditis  and  endocarditis.  The  pericardial 
sac  is  analogous  to  an  articular  synovial  cavity,  and  its  inflammations 
to  those  of  an  articular  synovitis.  The  relation  of  pericarditis  to  rheu- 
matism and  other  infectious  processes  further  strengthens  the  morbid 
analogy  and  common  etiology.  Pericarditis  may  also  follow  trauma  of 
the  precordia  (as  from  a  blow),  rupture  of  an  abscess  from  degeneration 
of  cheesy  mediastinal  glands,  and  perichondritis  or  necrosis  of  the  ribs 
and  sternum. 

The  products  of  a  pericardial  inflammation  may  be  serum,  fibrin, 
pus,  and  sometimes  blood.  These  vary  in  their  relative  amounts  in 
different  cases  or  in  different  stages  of  the  same  attack.  The  effusion 
of  serum  may  be  sufficient  to  distend  the  pericardial  sac  to  its  extreme 
limit,  or  so  slight  as  to  fail  to  lubricate  the  opposing  surfaces.    In  this 

20 


306  DISEASES    OF    THE    HEART 

latter  event  an  exfoliation  of  endothelium  allows  considerable  friction 
between  the  denuded  layers,  with  stimulation  of  fibrinous  exudation. 

Pericarditis  is  at  first  usually  circumscribed  but  may  become  general. 
There  is  congestion  of  the  vessels,  quickly  followed  by  an  exudate  which 
may  at  first  be  merely  a  thin  pellicle  easily  detached,  becoming  later 
a  fibrinous  mass  covering  the  affected  area.  The  exudate  may  be  likened 
in  consistency  and  appearance  to  buttermilk,  milk,  cream,  butter,  and 
soft  cheese.  Pus  cells  or  leucocytes  are  entangled  in  the  fibrin  and  the 
exudate  is  not  infrequently  tinged  with  blood.  The  blood  may  be  suffi- 
cient in  quantity  to  constitute  a  true  hemorrhage.  In  infancy  and  child- 
hood the  purulent  form  of  pericarditis  is  most  commonly  seen,  especially 
accompanying  empyema  of  the  left  side.  The  pericardial  sac  may  be 
distended  with  pus,  which  may  find  exit  into  the  mediastinum  or  burrow 
into  the  supraclavicular  region.  In  the  presence  of  plastic  fibrin  ad- 
hesions may  form  between  the  opposing  surfaces  so  that  after  repeated 
attacks  the  pericardial  sac  may  be  entirely  obliterated.  Miliary  tuber- 
cles may  stud  the  pericardium,  especially  in  connection  with  a  tuber- 
cular process  in  the  lung  or  mediastinal  glands.  In  the  serous  variety 
the  exudate  may  be  absorbed,  as  also  may  a  small  amount  of  pus,  with 
occasionally  little  or  no  remaining  evidence  of  the  disease.  The  perma- 
nent thickening  of  the  parietal  pericardium  and  the  presence  and  extent 
of  adhesions  depend  upon  the  amount  of  plastic  exudate  and  the  fre- 
quent recurrence  of  the  disease.  The  external  layer  of  the  pericardium 
is  occasionally  alone  involved  in  a  mediastinitis.  This  may  occur  with 
or  independently  of  a  pleuritis  or  pneumonia.  In  addition  to  a  thickened 
and  adherent  pericardium,  the  heart  is  usually  enlarged  from  dilatation 
due  to  the  accompanying  myocarditis,  and  chronic  valvular  lesions  are 
common  as  a  result  of  the  endocardial  involvement. 

Contracting  adhesions  of  the  sac  may  hamper  the  heart's  action  and 
impede  its  growth,  restricting  its  blood  supply  by  pressure  upon  the 
coronary  arteries,  and  thus  favor  degenerative  changes  in  the  myocardium 
with  resultant  myasthenia,  dilatation,  and  their  train  of  grave  conse- 
quences. 

Symptoms. — The  symptoms  of  pericarditis  in  early  childhood  are  not 
distinctive  from  other  cardiopathies  with  which  it  is  frequently  asso- 
ciated. There  may  be  febrile  symptoms  with  moderate  rise  of  tempera- 
ture, restlessness,  and,  in  some  neurotic  children,  delirium.  There  is 
usually  embarrassment  of  the  heart  action  and  occasionally  precordial 
uneasiness  or  distress  in  older  children,  with  palpitation  and  irregular 
pulse.  Dyspnoea,  orthopncea,  anxious  facies,  and  cyanosis,  may  be 
present,  dependent  upon  the  amount  of  the  pericardial  effusion  and  the 
extent  of  myocardial  and  endocardial  involvement.  In  severe  pneumonia 
and  extensive  pleurisy  the  symptoms  of  the  accompanying  pericarditis 
are  undistinguishable  save  as  a  prolongation  of  the  primary  disease.  In 
the  purulent  form  there  are  symptoms  of  septicaemia,  irregular  fever, 
chills,  and  sweating,  with  great  and  early  prostration. 

Early  oedema  of  the  thoracic  wall  is  suggestive  of  purulent  effusion. 


ACUTE    PERICARDITIS  307 

The  physical  signs  include  the  basic  double-friction  rub  early  in  the 
attack,  although  usually  missed  because  of  its  brief  duration;  also  the 
flatness  of  the  percussion  note  of  the  precordia  dependent  upon  the 
amount  of  effusion.  An  early  absorption  of  the  effusion  will  cause  the 
friction  sounds  to  reappear.  The  heart  sounds  are  muffled  and  indistinct ; 
the  apex  beat  may  appear  to  be  higher  and  is  diffused.  Even  with  a 
small  effusion  there  may  be  prominence  of  the  chest  wall  in  the  pre- 
cordial region.  In  young  infants  most  of  the  symptoms  and  physical 
signs  may  be  wanting,  the  patient  succumbing  to  the  purulent  invasion 
which  is  first  diagnosed  at  the  autopsy. 

The  average  duration  of  an  attack  of  acute  pericarditis  with  sponta- 
neous resorption  is  from  two  to  four  weeks.  The  rheumatic  form  is  apt 
to  be  persistent  or  to  recur  at  short  intervals,  covering,  with  its  exacer- 
bations and  remissions,  a  period  of  several  months. 

The  prognosis  as  to  life  in  an  acute  attack  is  good,  with  the  exception 
of  the  tubercular  and  purulent  varieties.  If  the  latter  be  not  relieved 
by  surgical  means  or  the  spontaneous  escape  of  pus  through  perforation, 
it  usually  leads  to  early  fatal  termination. 

Diagnosis. — The  diagnosis  of  pericardial  effusion  from  dilatation  of 
the  heart  and  empyema  is  at  times  extremely  difficult.  In  dilatation, 
even  with  bulging  precordia,  the  pulsations  of  the  heart  are  often 
"visible  in  a  wave-like  undulation  beneath  the  thin  chest  wall.  Car- 
diac murmurs,  if  present,  are  heard  more  distinctly.  If  the  area  of 
dulness  extend  far  beyond  the  point  of  apex  beat  it  is  suggestive  of 
pericardial  distention.  Fluid  in  the  pleural  cavity  may  be  misleading. 
Usually  palpation  and  auscultation  give  evidence  of  muffled  indistinctness 
of  systolic  impact  in  large  pericardial  effusions.  In  extensive  left  em- 
pyema and  serous  pleural  effusion  the  heart  should  show  some  displace- 
ment to  the  right,  which,  with  uninterrupted  dulness  to  the  extreme  left, 
will  explain  the  cause.  The  concurrence  of  pericardial  and  pleuritic  accu- 
mulations is  so  common  as  to  render  the  diagnosis  of  the  former  condi- 
tion extremely  difficult.  The  character  of  the  effusion  can  only  be  deter- 
mined by  aspiration,  although  toxic  symptoms  may  occasionally  point  to 
its  purulent  character  and  a  blood-count  may  show  leueoeytosis.  Local- 
ized pericarditis  with  a  walled-off  effusion  at  the  base  of  the  heart  may 
cause  dyspnoea  and  dysphagia  from  pressure  on  the  trachea  and  oesoph- 
agus, simulating  mediastinal  tumor.  From  this  it  is  to  be  differentiated 
by  the  slow  development  and  afebrile  history  of  the  latter,  although  the 
enlargement  of  tuberculous  glands  in  the  mediastinum  may  be  accom- 
panied by  elevation  of  temperature. 

Treatment. — If  a  pericarditis  be  diagnosed  in  the  early  or  dry  stage 
much  good  may  be  accomplished  by  the  application  of  ice  to  the  precor- 
dia. This  should  be  retained  in  position  by  a  bandage  or  vest  with  a 
layer  of  flannel  interposed  between  the  ice-bag  and  skin.  The  objection 
of  fretful  children  usually  subsides  under  the  comforting  effect  of  the 
cold.  This  treatment  is  believed  to  diminish  the  intensity  of  the  inflam- 
mation and  to  restrict  the  amount  of  effusion.    It  also  tends  to  quiet  the 


308  DISEASES    OF    THE    HEART 

cardiac  excitement  and  conserve  the  tone  of  the  heart  muscle.  "Where 
the  ice-bag  is  not  well  borne  and  when  the  heart's  action  shows  signs 
of  exhaustion,  especially  in  infants,  warm  applications  may  be  made  to 
the  precordia.  These  must  be  light,  and  care  must  be  exercised  to  avoid 
wetting  the  clothing.  An  ideal  for  this  is  a  small  Japanese  "  hot-box," 
separated  from  the  skin  by  a  few  layers  of  flannel. 

The  primary  infection  which  the  pericarditis  complicates  should  re- 
ceive appropriate  treatment,  whether  it  be  rheumatism,  pneumonia, 
pleurisy,  or  one  of  the  eruptive  fevers.  Two  important  desiderata  must 
be  borne  in  mind  in  the  treatment  of  pericarditis :  first,  to  limit  the  over- 
action  of  the  heart  by  all  reasonable  means ;  second,  to  relieve  the  gen- 
eral venous  stasis  which  attends  the  cardiac  insufficiency.  For  the 
former,  absolute  rest  in  a  semirecumbent  position  must  be  enforced,  since 
increasing  dyspnoea  and  palpitation  are  aggravated  by  the  dorsal  decu- 
bitus. On  no  account  should  the  patient  be  allowed  to  assume  the  upright 
position.  Codeine  is  valuable  for  the  relief  of  precordial  pain,  cardiac 
excitement  and  insomnia. 

For  the  heart-fag,  indicated  by  the  rapid  and  weak  pulse,  stimulants 
are  required,  of  which  strychnia  is,  perhaps,  the  best.  Great  tact  is  neces- 
sary in  the  administration  of  strychnia  to  children,  especially  in  car- 
diopathies where  excitement  is  productive  of  much  harm.  The  bitter 
taste  of  the  alkaloid  frequently  arouses  the  child's  opposition  to  all 
medication  and  even  to  food  and  drink,  whereas  the  hypodermic  needle, 
if  awkwardly  employed,  induces  a  state  of  frantic  terror.  This  may  be 
avoided  by  adroitness  and  dexterity  that  prevent  the  child  from  witness- 
ing the  subcutaneous  injection. 

Digitalis  is  contraindicated  in  the  early  stage  of  pericardial  inflamma- 
tions. In  experienced  hands  it  may  occasionally  do  good  in  the  rapidly 
failing  and  intermittent  pulse  of  a  later  stage  when  other  remedies  have 
proved  ineffective.  Caffeine  citrate  is  useful  and  may  be  given  by  the 
mouth.  The  large  and  tender  liver,  scanty  urine,  and  evidences  of  venous 
stasis  below  the  diaphragm,  may  be  greatly  relieved  by  free  diuresis 
and  hydragogue  catharsis.  Small  doses  of  calomel  and  soda,  frequently 
repeated,  should  be  followed  by  salines.  If  the  signs  of  pericardial 
effusion  be  marked  this  should  be  repeated  sufficiently  often  to  secure 
several  watery  stools  daily.  Instead  of  weakening  the  child  this  treat- 
ment will  frequently  relieve  dyspnoea.  Free  diuresis  may  be  secured 
by  potassium  citrate  or  acetate,  or  by  diuretin,  two  to  five  grains  (0.13- 
0.32  Gm.),  thrice  daily.  In  older  children  a  reliable  infusion  of  digitalis 
leaves,  one  to  four  drachms  (3.75-15.0  Cc),  may  prove  efficient.  That 
these  measures  promote  resorption  of  pericardial  effusion  in  many  cases 
there  is  little  reason  to  doubt.  As  in  the  other  acute  cardiopathies,  the 
diet  requires  special  attention  that  the  patient's  strength  be  maintained 
without  distressing  complications  from  distended  stomach  and  bowels. 
To  this  end  concentrated,  easily  digested  liquids,  such  as  liquid  pep- 
tonoids,  beef  juice,  somatose  and  milk,  should  be  given  in  small  quanti- 
ties at  intervals  of  from  two  to  four  hours. 


CHRONIC    PERICARDITIS  309 

The  fatality  of  purulent  pericarditis  renders  imperative  the  evacua- 
tion of  the  pus.  So,  too,  the  overdistended  pericardium  should  be  re- 
lieved of  serum  when  the  degree  of  pressure  threatens  the  action  of  the 
heart.  Exploratory  puncture  may  be  made  with  an  aspirating  needle  to 
determine  the  character  of  the  tluid.  If  serous,  it  may  be  withdrawn 
by  aspiration.  Much  discussion  has  arisen  as  to  the  most  eligible  site 
for  puncture.  Two  things  to  be  avoided  are  wounding  the  heart  and 
puncturing  the  internal  mammary  arteries,  which  parallel  the  sternum 
about  one-half  inch  distant  from  either  border.  A  puncture  in  the  fifth 
interspace  on  either  side  of  the  sternum  will  reach  the  pericardial  fluid 
with  but  little  danger  of  touching  the  heart.  The  internal  mammary 
artery  may  be  avoided  either  by  introducing  the  needle  close  to  or  an  inch 
away  from  either  sternal  border.  If  pus  be  demonstrated  by  aspiration, 
perieardotomy  should  be  performed. 

ADHERENT   PERICARDIUM — CHRONIC   PERICARDITIS. 

Post-mortems  frequently  show  adherent  pericardium  in  the  absence 
of  ante-mortem  diagnosis  of  pericardial  inflammation.  There  is  usually 
a  history  of  pneumonia,  pleurisy,  tuberculosis,  or  liver  disease,  and  fre- 
quently of  rheumatism,  although  the  symptoms  of  the  latter  may  have 
been  reported  as  insignificant.  The  pericardium  is  found  to  be  thick- 
ened, and  adhesions  between  its  opposing  layers  occur  in  patches  or 
throughout  its  entire  extent,  completely  obliterating  the  sac.  Occasion- 
ally a  deposition  of  lime  salts  is  found  upon  the  visceral  layer  in  plaque- 
like crusts,  presumably  due  to  the  absorption  of  purulent  exudate.  The 
outer  layer  may  also  be  adherent  to  the  adjacent  pleura,  diaphragm,  and 
mediastinal  structures.  The  heart  nearly  always  is  enlarged,  its  ven- 
tricles, especially  the  left,  being  hypertrophied  but  more  frequently 
dilated.  Evidences  of  myocarditis  and  endocarditis,  such  as  degenera- 
tion and  sclerotic  lesions  of  the  heart  wall  and  hyperplastic  deformities 
of  the  valves  and  ostia  are  rarely  absent. 

Chronic  pericarditis  may  result  from  the  successive  recurrence  of 
acute  attacks,  or  it  may  develop  insidiously  and  be  chronic  from  the 
beginning.  It  has  been  found  in  the  new-born  infant,  showing  its  de- 
velopment in  utero,  also  at  the  post-mortems  of  young  infants  where  its 
presence  was  unsuspected  during  life. 

Among  the  signs  of  adherence  of  the  pericardium  to  adjacent 
structures  are  permanent  extension  of  precordial  dulness,  usually 
obscured  heart  sounds  and  systolic  retraction  of  the  chest  wall  over  the 
apex  beat,  followed  by  a  diastolic  impact.  The  same  retraction  may  be 
seen  below  the  angle  of  the  left  scapula  in  the  tenth  interspace  (Broad- 
bent's  sign).  Diastolic  collapse  of  the  cervical  veins  is  sometimes  present 
(Friedreich's  sign).  Persistent  enlargement  of  the  liver  in  a  child  with 
venous  stasis,  anasarca,  and  ascites,  in  the  absence  of  known  causative 
lesion,  should  suggest  chronic  pericarditis. 

Adherent  pericardium  is  a  permanent  lesion.  The  prognosis  is  un- 
favorable because  of  secondary  lesions  of  the  heart  and  changes  in  other 


310  DISEASES    OF    THE    HEART 

viscera  from  interference  with  the  circulation.     Death  may  occur  sud- 
denly from  cardiac  failure. 

The  condition  demands  free  action  of  the  bowels  and  kidneys,  the 
withdrawal  of  effusions  by  paracentesis  when  necessary,  reduction  of 
the  heart's  work  to  the  minimum  by  rest  in  bed,  and  the  exhibition  of 
cardiac  tonics  and  stimulants,  such  as  strychnia,  digitalis,  strophanthus, 
caffeine  citrate,  and  iron  for  the  progressive  anamiia.  Under  favorable 
conditions,  with  great  care,  life  may  continue  for  many  months. 


CHAPTER    IX 
DISEASES    OF    THE    RESPIRATORY    TRACT 

RHINITIS,  ACUTE  AND  CHRONIC — CORYZA  ;    ACUTE  NASAL  CATARRH  ;    COLD  IN 

THE    HEAD 

Acute  rhinitis  is  the  most  common  disorder  of  childhood  and  may  be 
seen  in  earliest  infancy.  Three  factors  are  prominent  in  its  etiology, — 
viz.,  lowered  vitality,  exposure  to  cold  and  dampness,  and  the  presence 
of  pathogenic  bacteria. 

A  predisposition  to  nasal  catarrh  may  be  inherited.  This  appears 
either  as  a  proneness  of  mucous  tissues  to  develop  pathologic  conditions, 
or  in  the  malformation  of  the  facial  and  nasal  bones  which  favors 
vascular  congestion.  Rhachitic  and  lymphatic  children  are  favorable 
subjects  for  rhinitis,  as  are  the  underfed,  half-clad  and  poorly-housed 
children  of  squalor.  The  victims  of  malhygiene,  however,  are  not  always 
the  neglected  children  of  poverty,  since  in  homes  of  affluence  the  too 
frequently  overheated  rooms,  imperfect  ventilation,  and  indoor  restraint 
lessen  the  stability  of  the  vascular  system,  thus  favoring  local  congestions 
upon  the  slightest  exposure  to  lowered  temperature.  The  first  stage  of 
rhinitis  is  characterized  by  vascular  engorgement  of  the  nasal  mucosa, 
transudation  of  serum  with  lachrymation,  sneezing,  and  a  feeling  of 
frontal  fulness.  The  swelling  of  the  mucosa  diminishes  the  lumen  of 
the  nasal  fossae,  causing  partial  obstruction  to  inspiration.  A  smarting 
sensation  is  produced  by  the  impingement  of  air  upon  the  inflamed 
Schneiderian  membrane.  In  the  infant  this  obstruction  may  so  inter- 
fere with  nasal  respiration  as  to  render  continuous  nursing  difficult  or 
impossible,  so  that  insufficient  nutrition  may  be  a  direct  result. 

Symptoms. — Rise  of  temperature,  which  may  be  slight,  100°  to  101°  F. 
(37.5°-38°  C),  headache,  general  malaise  or  irritability,  usually  usher 
in  a  common  cold.  Occasionally  at  this  stage  the  attack  aborts,  all  the 
symptoms  disappearing  in  a  few  hours.  As  the  congestion  of  the  vessels 
is  somewhat  diminished  the  mouths  of  the  muciparous  follicles  pour  out 
their  secretion,  causing  increased  viscidity  of  the  nasal  discharge.  The 
sensitiveness  of  the  Schneiderian  membrane  lessens,  as  does  obstruction  to 
the  passage  of  air  through  the  nasal  fossae.  The  mucoid  catarrh  becomes 
mucopurulent  and  may  cause  excoriation  of  the  integument  of  the  alae 
nasi  and  upper  lip.  A  wide  range  of  variation  is  observed  in  the  in- 
tensity of  the  symptoms  in  different  attacks.  Acute  rhinitis  may  occur 
sporadically  but  more  often  appears  in  epidemic  form.  It  is  frequently 
confined  to  a  family  or  the  inmates  of  a  house  and  is  probably  communi- 
cable. The  bacterial  examination  of  the  discharge  in  coryza  shows  all 
the  microbic  varieties  usually  present  on  the  nasal  mucous  membrane 

311 


312  DISEASES    OF    THE    RESPIRATORY    TRACT 

but  in  vastly  increased  numbers.  Of  these  no  one  lias  been  selected  to 
bear  the  exclusive  etiologic  responsibility. 

From  an  uncomplicated  coryza,  under  favorable  conditions,  the  child 
recovers  in  one  or  two  weeks.  The  tendency  to  recurrence  upon  exposure 
is  marked,  so  that  a  succession  of  acute  attacks  may  follow  with  brief 
or  almost  imperceptible  intervals  of  remission.  The  Schneiderian  mucosa 
may  show  local  tumefaction  and  hyperplasia  with  submucoid  hyper- 
trophy. This  hypertrophy  may  extend  to  the  osseous  structures,  seen  in 
the  enlargement  of  the  turbinated  bones  which,  with  the  increase  in  bulk 
and  vascularity  of  the  soft  tissues,  cause  varying  degrees  of  obstruction. 

Chronic  rhinitis  is  not  infrequently  the  result  of  oft-recurring  attacks 
of  the  acute  form.  The  line  can  not  be  sharply  drawn  between  prolonged 
continuation  of  a  series  of  acute  or  subacute  attacks  and  the  acute  exacer- 
bations of  a  mild  chronic  catarrh.  Neither  is  the  clinical  distinction 
always  evident  in  chronic  rhinitis  between  the  simple  and  hypertrophic 
varieties.  So,  too,  the  character  of  the  nasal  discharge  of  chronic  catarrh 
in  the  same  individual  may  appear  as  mucoid,  mucopurulent  or  puru- 
lent. As  a  rule  the  discharge  is  not  so  profuse  in  chronic  as  in  acute 
rhinitis.  It  may  be  gray,  green,  bloody,  abundant  or  scanty,  and  may 
show  a  tendency  to  form  crusts.  These,  decomposing,  give  rise  to  a 
most  offensive  odor  (ozena).  Ulcerative  lesions  of  the  mucosa  may 
occur.  In  older  children  the  accessory  nasal  sinuses  (antrum,  frontal 
or  ethmoidal)  may  become  involved  in  a  local  or  general  sinusitis. 
Syphilitic  heredity  may  induce  bony  necrosis  with  a  fetid,  purulent  or 
ichorous  discharge  and  more  or  less  destruction  of  the  cribriform  or  nasal 
bones  resulting  in  ' '  saddle  nose. ' '  Chronic  rhinitis  is  frequently  caused 
by  imperfect  ventilation  and  retained  secretion,  due  to  the  presence  of 
adenoid  growths  in  the  rhinopharynx.  It  may  also  be  caused  by  the 
presence  of  a  foreign  body  in  the  nares.  In  the  latter  case  the  unilateral 
and  purulent  character  of  the  discharge  is  suggestive.  Nasal  polypi, 
though  rare  in  childhood,  may  occasion  a  catarrhal  discharge  from  the 
side  involved. 

The  atrophic  form  of  rhinitis,  although  rare  in  childhood,  has  been 
reported  as  early  as  the  fourth  year.  When  the  change  from  turgescence 
and  hypertrophy  to  atrophy  of  the  nasal  tissues  occurs  it  is  impossible 
to  determine.  Occasionally  atrophic  changes  have  developed  insidiously 
with  no  history  of  acute  rhinitis,  attention  being  first  attracted  by  the 
ozena.  If  advanced,  an  examination  shows  enlargement  of  the  nasal 
chambers,  with  adherent  crusts  of  dried  secretion. 

The  effects  of  rhinitis,  immediate  and  remote,  are  as  serious  to  the 
well-being  of  the  child  as  the  disorder  is  common.  Among  the  symptoms 
of  chronic  rhinitis,  in  addition  to  the  discharge,  are  frontal  fulness  or 
headache,  especially  on  arising  in  the  morning ;  bad  taste,  impaired  appe- 
tite, perversion  of  the  special  senses — hearing,  taste  and  smell;  indica- 
tions of  posterior  nasal  irritation — screatus,  snuffling  and  spitting ;  dimin- 
ished vocal  resonance,  fetid  breath,  and  coated  tongue,  inexplicable  by 
other  conditions.     Among  the  secondary  effects  are  otitis,  through  con- 


RHINITIS  313 

tiguity  of  tissue,  with  all  its  results;  extension  of  catarrhal  lesions  to 
any  part  of  the  respiratory  mucosa;  impaired  digestion  from  decom- 
posing nasal  secretions  which  have  been  swallowed,  and  conjunctivitis 
and  keratitis  from  extension  through  the  lachrymal  duct.  But  most 
far-reaching  in  its  baleful  influence  is  the  obstruction  to  respiration 
caused  by  the  nasal  stenosis. 

Prognosis. — Rhinitis  rarely,  if  ever,  destroys  life,  except  through 
some  of  its  many  secondary  affections,  hence  the  too-frequent  indiffer- 
ence to  nasal  catarrhs  on  the  part  of  both  layman  and  practitioner. 
The  diagnosis,  ' '  common  cold, ' '  unfortunately  relieves  the  parental  mind 
of  all  anxiety,  and  a  second  professional  call  is  rarely  encouraged  "unless 
something  serious  develops." 

Though  atrophic  rhinitis,  strictly  speaking,  may  never  be  cured, 
the  fetor  and  crust  formation  may  be  minimized  by  persistent  appro- 
priate treatment,  such  as  the  use  of  oily  sprays  to  soften  the  crusts, 
thorough  cleansing  twice  daily  with  atomization,  or,  better,  irrigation 
with  a  mild  alkaline  antiseptic  solution  (Formulas  11  and  12).  Crusts 
that  are  refractory  to  irrigation  must  be  gently  removed  by  a  cotton- 
wrapped  probe  dampened  in  a  weak  lysol  solution.  Deodorants  and 
stimulating  solutions  and  powders  should  be  used  by  atomization  and 
insufflation. 

Treatment  of  Acute  Rhinitis. — The  busy  physician  would  better  devote 
some  of  his  valuable  time  to  the  enlightenment  of  parents  concerning 
the  far-reaching  possibilities  of  the  neglected  "cold  in  the  head"  than 
later  to  expend  all  his  energies  in  diagnosis  and  treatment  of  the  patho- 
logical conditions. 

The  child  should  be  put  to  bed,  though  the  fever  may  be  slight  and 
the  malaise  not  pronounced.  A  full  dose  of  castor  oil  should  be  given, 
or  tablets  containing  calomel,  ipecac,  and  soda  (Formulas  24  and  25  . 
may  be  given  every  hour  for  four  doses,  then  every  two  hours  for  six 
doses.  If  necessary  this  should  be  followed  by  citrate  of  magnesia  or 
other  saline  to  secure  repeated  bowel  movements.  Warm  bathing  is 
always  in  order  and  is  especially  valuable  if  the  fever  be  high.  Hot  com- 
presses may  relieve  the  headache  and  sensation  of  tightness.  The  extrem- 
ities should  be  kept  warm,  and  hot  pediluvia.  with  or  without  mustard, 
are  valuable  adjuncts.  Careful  nasal  irrigation  with  tepid  normal  salt 
solution  may  be  used  three  or  four  times  daily  to  remove  the  tenacious 
mucus.  Atomization  of  lavolene  or  albolene  should  follow  the  irri- 
gation to  soothe  and  protect  the  irritable  mucosa  (Fig.  71,  Part  I  .  In 
extreme  stenosis,  cautious  applications  twice  daily  of  one  or  two  per  cent, 
solution  of  cocaine  will  deplete  the  engorged  mucosa.  The  nasal  obstruc- 
tion to  nursing  in  the  very  young  infant  may  be  relieved  by  instillation 
of  a  drop  or  two  of  adrenalin  solution  (1:5000)  in  each  nostril. 

The  spiritus  mindereri  is  valuable  to  promote  diuresis  and  diaphore- 
sis, which  may  be  further  aided  by  hot  drinks  of  lemonade,  aromatic 
teas,  or  diluted  milk.  In  severe  cases  with  high  temperature  the  hot- 
pack  may  be  applied.     There  should  be  an  abundant  supply  of  fresh 


314  DISEASES    OF    THE    RESPIRATORY    TRACT 

air  warmed  to  70°  F.  (21°  C),  its  dryness  lessened  by  the  slow  evapora- 
tion of  water  containing  turpentine,  thymol,  or  eucalyptol. 

The  diet  should  be  restricted  to  fluids  in  small  quantities,  and  even 
the  nursling  should  be  freely  supplied  with  water.  The  first  outing 
after  convalescence  should  depend  upon  the  weather,  dampness  and 
strong  winds  being  avoided. 

Treatment  of  Chronic  Rhinitis. — In  the  chronic  rhinitis  of  children 
foreign  bodies,  extreme  hypertrophies,  exostoses,  marked  deflection  of 
the  septum  and  polypoid  or  adenoid  growths,  if  present,  should  be 
removed.    Most  of  these  cases  may  profitably  be  referred  to  the  specialist. 

Chronic  simple  or  hypertrophic  rhinitis  in  a  child  is  rarely  incurable. 
Its  proverbial  intractability  is  the  result  of  fresh  accessions  from  the 
frequent  recurrence  of  causative  conditions.  Of  primary  importance  is 
attention  to  the  child's  general  health,  as  catarrhal  processes  luxuriate 
in  lowered  vitality.  Constipation  and  indigestion  must  be  relieved. 
The  quality  of  the  blood  should  be  improved  by  regular  habits,  fresh 


Fig.  144. — Nasal  irrigation. 

air,  exercise,  nutritious  food,  and  the  judicious  administration  of  hsemic 
tonics  and  restoratives,  as  iron,  manganese,  arsenic,  quinine  and  cod- 
liver  oil.  For  frequently  recurrent  attacks  it  may  be  necessary  to 
change  residence  to  a  more  equable  climate. 

The  main  objects  of  treatment  should  be  to  relieve  irritation,  deplete 
congestion,  and  stimulate  the  morbid  mucosa  to  normal  activity.  The 
excessive  mucoid  secretion  furnishes  a  favorable  culture  medium  for 
residential  bacteria,  which  multiply  therein  with  pus  formation  and 
decomposition.  Irritating  toxins  and  decomposing  debris  perpetuate  the 
morbid  process.  The  removal  of  the  discharge  is  the  first  essential  in  the 
local  treatment.  Twice  daily,  or  oftener  if  the  case  demands,  the  nasal 
mucosa  must  be  cleaned  by  mild,  tepid  solutions  of  alkalies,  because  of 
their  well  known  property  of  dissolving  mucus.  Combinations  of  an 
alkali  with  antiseptics,  such  as  sodium  bicarbonate,  biborate,  and  chloride, 
with  eucalyptol,  menthol,  or  carbolic  acid,  are  frequently  useful.     Solu- 


RHINITIS  315 

tions  of  mercuric  chloride  or  potassium  permanganate  may  be  neces- 
sary when  the  discharge  is  very  purulent.  Redundancies  and  hyper- 
trophies may  call  for  astringent  applications,  as  solutions  of  alum, 
tannic  acid,  sulphate  or  sulphocarbolate  of  zinc.  In  older  children 
cotton  tamponage  with  hygroscopic  or  astringent  agents,  as  glycerin  or 
glycerite  of  tannin,  may  be  employed  (Formula  1-4).  In  the  same  way. 
iodine  or  iodide  of  potassium  in  glycerin  and  water  may  be  applied, 
the  tampon  being  allowed  to  remain  for  several  hours.  Cleansing  irriga- 
tion requires  the  nasal  douche  or  atomizer.  The  infant's  nasal  tract 
may  be  irrigated  by  means  of  a  half-ounce  syringe  with  a  soft  rubber 
tip,  which  occludes  the  nostril.  As  the  child  lies  upon  its  side  the  tepid 
fluid  is  introduced  very  gently  into  the  upper  nostril  and  allowed  to  flow 
freely  from  the  lower  (Fig.  14-1).  Older  children  may  be  taught  to 
use  the  nasal  douche,  allowing  the  fluid  to  circulate  freely  from  one  side 
of  the  nasopharynx  to  the  other,  the  lower  part  of  which  is  occluded 
by  the  apposition  of  the  soft  palate  to  the  posterior  wall.  This  action 
of  the  palate  may  be  secured  by  breathing  through  the  mouth  during 
irrigation. 

Prophylaxis.     (See  Hygiene.) 

MEMBRANOUS   RHINITIS. 

A  form  of  acute  rhinitis  is  seen  in  children  in  which  a  membranous 
deposit  appears  over  the  nasal  mucosa.  This  croupous  or  membranous 
rhinitis  resembles  nasal  diphtheria,  from  which  it  is  frequently  indis- 
tinguishable save  by  bacteriological  examination.  The  membranes  may 
extend  to  the  nostrils,  where  they  appear  as  a  grayish-white  croupous 
deposit,  which  when  stripped  from  the  underlying  mucosa  leaves  that 
surface  clean  without  bleeding.  When  removed  the  membranes  re-form 
in  a  few  days  and  by  their  presence  narrow  the  lumen  of  the  nasal 
passages. 

The  chief  interest  lies  in  its  differentiation  from  diphtheria,  which 
must  still  depend  mainly  upon  the  isolation  of  the  Klebs-Loeffler  organ- 
ism. However,  the  history  of  exposure,  the  presence  of  a  membranous 
exudate  in  other  localities,  the  profound  systemic  disturbance,  gland- 
ular enlargements,  foul-smelling  discharge  from  the  nose,  albuminuria 
and  the  sequel,  neuritis,  point  almost  positively  to  diphtheria.  More- 
over, diphtheritic  membranes  are  more  closely  adherent,  and  bleeding 
follows  their  removal. 

In  all  cases  the  appearance  of  membrane  in  the  nares  should  lead 
to  a  suspicion  of  diphtheria  and  to  prompt  isolation  of  the  patient  until 
cultural  tests  have  been  made. 

The  prognosis  is  favorable,  though  the  duration  may  extend  to  three 
or  four  weeks. 

The  treatment  consists  in  local  cleansing  with  alkaline  solutions  and 
astringent  applications  (Formulas  10  to  15).  Calomel  and  tincture  of 
the  chloride  of  iron  in  full  doses  are  usually  administered  to  combat  the 
hyperinosis. 


316  DISEASES    OF    THE    RESPIRATORY    TRACT 

SYPHILITIC   RHINITIS. 

The  only  indication  of  syphilis  in  the  neAV-born  may  be  "snuffles," 
with  little  or  no  discharge  from  the  nostrils.  Occasionally,  however, 
there  may  be  a  mucosanious  discharge  or  even  epistaxis.  The  tendency 
to  necrosis  of  the  nasal  bones  with  deformity  rarely  occurs  in  congenital 
rhinitis.  The  mistake  is  frequently  made  in  regarding  every  case  of 
snuffles  in  young  infants  as  syphilitic.  Regurgitated  milk  in  the  pos- 
terior nares  is  a  frequent  cause  of  snuffles  and  respiratory  obstruction. 

The  coryza  of  syphilis  usually  develops  from  the  second  to  the  fourth 
week. 

The  treatment  is  constitutional  by  mercurial  inunction  and  attention 
to  nutrition.  (See  Syphilis.)  Local  treatment  consists  in  cleansing  the 
nose  with  oily  applications  (Formula  9)  by  atomizer,  a  cotton- wrapped 
probe,  or  nasal  dropper.  The  difficulty  in  nursing,  from  the  nasal 
accumulations,  requires  their  frequent  removal.  If  necessary  a  rubber 
tube  may  be  passed  through  into  the  pharynx  and  allowed  to  remain 
in  situ  during  each  nursing. 

nasal  polypi. 

Nasal  polypi,  both  mucous  and  fibrous,  are  occasionally  seen  in  child- 
hood, though  rarely  before  the  sixth  year.  Their  most  common  location 
is  the  middle  meatus,  from  the  outer  wall  of  which  they  depend  by  a 
more  or  less  elongated  pedicle.  They  may  be  single,  multiple,  or  bilateral, 
and  give  rise  to  symptoms  of  occlusion  and  mild  chronic  rhinitis.  They 
are  aggravated  by  dust-laden  atmosphere  and  damp  weather. 

The  diagnosis  is  made  by  examination  with  speculum  and  mirror, 
and  their  removal,  when  pedunculated,  is  best  accomplished  by  means 
of  the  wire  snare,  or  they  may  be  seized  with  the  forceps  and  twisted 
off.  The  resulting'  hemorrhage,  if  severe,  may  be  checked  by  pack- 
ing with  a  strip  of  gauze  saturated  with  a  five  per  cent,  solution  of 
antipyrin. 

Foreign  Bodies  in  the  Nose. — Children  and  infants  very  frequently 
introduce  small  objects,  such  as  peas,  beans,  and  beads,  into  the  nose 
where  they  become  impacted.  If  long  retained  the  mucous  membrane 
swells  and  partly  or  entirely  conceals  the  object.  The  symptoms  are 
those  of  partial  occlusion  with  unilateral  discharge.  The  probe  may 
reveal  their  presence  if  the  mirror  and  speculum  fail.  Specially  devised 
scoops  and  forceps  may  be  necessary  to  effect  their  removal,  but  they 
may  often  be  easily  removed  by  engaging  them  in  the  loop  of  a  wire 
snare.  If  recently  introduced,  the  body  may  be  dislodged  by  air  forced 
into  the  opposite  nostril. 

EPISTAXIS — NOSE-BLEED. 

Epistaxis  is  common  in  children,  especially  in  boys  between  the  ages 
of  four  and  twelve  years.  It  is  rarely  seen  earlier.  Syphilitic  rhinitis  in 
infants  is  sometimes  accompanied  by  nasal  bleeding,  though  epistaxis  is 
not  a  frequent  feature  in  the  hemorrhages  of  the  new-born. 


EPISTAXIS  317 

Nose-bleed  may  be  the  result  of  capillary  oozing  or  direct  hemorrhage 
from  rupture  of  the  arterioles  in  any  part  of  the  nasal  mucosa,  although 
its  most  frequent  site  is  the  anterior  and  inferior  portion  of  the  septum. 
Usually  it  is  trivial  in  character  but  occasionally  causes  extreme  ex- 
sanguination. 

Several  explanations  have  been  offered  for  the  frequency  of  epistaxis 
in  childhood,  among  which  are  the  greater  tendency  to  local  congestions 
from  trifling  causes,  the  fragility  of  the  vessel  walls  and  the  relative 
thinness  of  the  supporting  mucosa. 

The  causes  may  be  local  or  general.  Among  the  former  are  trauma- 
tisms, blows,  falls,  picking  at  the  nose,  foreign  bodies,  adenoids,  varicosi- 
ties, erosions,  and  chronic  rhinitis.  General  causes  include  all  conditions 
which  favor  congestion,  either  active  or  passive,  such  as  typhoid  fever, 
diphtheria,  and  measles ;  violent  exercise ;  mental  excitement  and  car- 
diac hypertrophy;  constipation,  cold  extremities  and  whooping  cough; 
also  stasis  from  heart,  lung,  liver,  and  kidney  lesions.  Various  blood 
conditions  favor  epistaxis,  as  haemophilia,  scurvy,  purpura,  anaemia, 
chlorosis,  leukaemia,  rheumatism,  and  syphilis. 

Epistaxis  frequently  occurs  during  sleep,  and,  if  the  blood  be 
swallowed  and  vomited,  may  be  misinterpreted.  Epistaxis  may  occur 
only  rarely  from  some  accident  or  it  may  be  recurrent.  If  frequent 
it  may  be  serious  from  the  resultant  anaemia.  Habitual  nose-bleed 
is  suggestive  of  cardiac  incompetency,  and  examination  will  often 
reveal  valvular  defects.  Obstinate  constipation  and  badly  ventilated 
school-rooms  are  undoubtedly  responsible  for  many  cases  of  recurrent 
nose-bleed. 

Treatment. — The  child  should  be  kept  quiet  in  the  sitting  position. 
For  obstinate  epistaxis  the  bleeding  point  should  be  located  and  pressure 
applied,  if  possible.  This  may  be  accomplished  when  hemorrhage  is  in 
the  anterior  portion  by  compressing  the  ala  against  the  septum.  In- 
sufflation of  astringent  solutions,  as  alum,  tannin,  sulphate  of  zinc, 
antipyrin,  etc.,  are  sometimes  useful.  Adrenalin  solution  (1  :  1000) 
may  be  applied  on  a  swab.  The  bleeding  may  be  arrested  through 
reflex  action  by  the  momentary  application  of  cold  to  the  face,  but  more 
particularly  to  the  cervical  and  dorsal  spine.  Revulsion  may  be  secured 
through  hot  pediluvia  and  evacuation  of  the  bowels  by  enema.  If 
other  means  fail,  tamponage  or  plugging,  anterior  or  posterior,  should 
be  resorted  to.  A  strip  of  gauze  introduced  into  the  naris  will  favor 
clotting.  Pressure  may  be  secured  by  means  of  an  ice-bag  or  rhineuryn- 
ter.  If  one  is  not  at  hand  it  may  be  improvised  from  a  condom,  finger- 
stall or  even  a  kid-glove  finger,  which,  tied  over  the  end  of  a  catheter, 
is  introduced  and  inflated,  the  end  being  secured  by  a  thread.  One 
caution  in  the  use  of  rubber  bags :  the  distal  end  should  not  project 
through  the  posterior  naris,  as  yielding  in  the  line  of  least  resistance  the 
rubber  will  balloon  in  the  pharynx.  For  permanent  cure  of  varicose 
areas  cauterization  may  be  necessary. 

In   children   subject  to  frequent  epistaxis   the   predisposing   cause 


318  DISEASES    OF    THE    RESPIRATORY    TRACT 

should  be  sought  in  some  of  the  before-mentioned  conditions  and  meas- 
ures instituted  for  its  relief. 

A  thorough  examination  with  careful  review  of  the  child's  history- 
may  bring  to  light  organic  or  systemic  conditions  little  suspected.  A 
frequent  mistake  lies  in  confining  treatment  to  the  seat  of  hemorrhage 
and  overlooking  the  causative  constitutional  condition. 

CONGENITAL   LARYNGEAL   STRIDOR. 

Rarely  a  peculiar  defect  is  noticed  in  the  respiration  of  very  young 
infants.  The  act  is  accompanied  by  a  purring  sound,  sometimes  ending 
in  a  gasp  or  crow,  as  though  the  entrance  of  air  were  momentarily  pre- 
vented by  some  obstruction  in  the  larynx.  This  noisy  inspiration  is 
not  usually  continuous;  is  increased  by  excitement,  and  disappears 
during  sound  sleep. 

In  the  absence  of  malformations  of,  or  growths  in,  the  upper  respira- 
tory tract,  this  congenital  stridor  is  explained  by  some  as  a  neurosis. 
There  is  thought  to  be  incoordination  between  the  inspiratory  muscles 
of  the  chest  and  those  which  control  the  opening  of  the  glottis.  The 
inrush  of  air,  in  response  to  chest  expansion,  finds  the  vocal  cords 
insufficiently  relaxed,  a  form  of  laryngeal  chorea. 

The  fact  that  in  some  of  these  infants  the  epiglottis  is  seen  to  be 
unduly  curved  has  suggested  that  its  inopportune  approximation  may 
be  the  cause  of  the  stridor.  Prolapse  of  the  mucosa  of  the  laryngeal 
ventricles,  or  falling  in  of  the  relaxed  glottic  walls,  has  also  been  offered 
in  explanation. 

Whatever  may  be  the  cause,  expiration  is  unimpeded,  the  voice  is 
clear,  cyanosis  is  absent,  and  there  is  no  interference  in  normal  develop- 
ment. The  stridor  gradually  disappears  in  later  infancy.  As  the 
child's  health  and  growth  do  not  seem  to  be  affected,  no  treatment  is 
necessary. 

Congenital  stridor  is  not  to  be  confused  with  laryngismus  stridulus, 
a  disorder  rarely  seen  before  dentition  and  usually  associated  with 
rhachitis  and  tetany. 

ACUTE   LARYNGITIS. 

Though  acute  laryngitis  is  common  to  all  ages  it  assumes  special 
importance  among  the  diseases  of  childhood.  The  reason  for  this  is  the 
greater  tendency  at  this  age  to  respiratory  stenosis,  not  only  from  the 
small  lumen  of  the  child's  larynx,  which  can  ill  afford  reduction  from 
inflammatory  thickening,  also  from  greater  plasticity  of  the  exudate  in 
acute  catarrhs,  but  principally  from  the  predisposition  to  laryngospasm. 
In  fact,  the  gravity  of  simple  catarrhal  inflammation  of  the  larynx  is 
in  direct  ratio  to  the  tendency  to  spasm  which  is  due  to  the  instability 
of  the  nervous  system. 

Laryngitis  is  seen  most  frequently  between  the  second  and  fifth  years. 
Like  other  inflammations  of  the  respiratory '  mucosa,  it  is  undoubtedly 
due  to  microbic  infection  and  rarely  if  ever  occurs,  except  from  trauma- 


ACUTE    LARYNGITIS  319 

tism,  in  the  absence  of  other  lesions  of  the  respiratory  tract,  such  as 
rhinitis,  adenoids,  pharyngitis,  tonsillitis,  or  bronchitis.  It  may  occur 
secondarily  to  most  of  the  acute  exanthems,  especially  measles,  scarlet 
fever,  and  variola. 

Among  the  exciting  causes  are  exposure  to  cold  and  dampness,  also 
traumatisms  from  direct  violence  or  from  inhalation  of  irritating  vapors 
or  fluids.  A  predisposition  to  laryngeal  affections  is  seen  in  some  chil- 
dren who  show  other  evidences  of  lymphatism,  and  may  possibly  be 
explained  by  the  richness  in  lymphoid  bodies  of  the  subglottic  mucosa. 

Symptoms. — The  symptoms  of  acute  catarrhal  laryngitis  are  those  of 
laryngeal  irritation  and  occlusion  of  varying  degree, — viz.,  cough  and 
obstructed  respiration.  The  cough  is  characteristically  violent,  explosive, 
and  is  variously  described  as  harsh,  barking,  metallic,  brassy,  or  clang- 
ing. Aside  from  these  symptoms  the  child  may  show  little  evidence 
of  general  disturbance.  Usually  there  is  a  slight  rise  in  temperature, 
rarely  a  high  fever,  in  uncomplicated  cases.  The  temperature,  cough  and 
hoarseness,  with  malaise  and  anorexia,  may  continue  for  a  week  or 
more  without  alarming  symptoms.  On  the  other  hand,  the  invasion 
may  occur  unexpectedly  at  night,  with  the  classical  symptoms  of  croup. 
The  child  is  suddenly  aroused  with  loud,  clanging  cough,  and  crowing 
inspirations  which  can  be  heard  throughout  the  house.  With  staring 
eyes,  distended  nostrils,  and  pallid  face  bedewed  with  perspiration,  he 
clutches  at  his  throat  in  the  terror  of  impending  suffocation.  The  in- 
spiration is  labored  and  stridulous.  The  suprasternal,  clavicular,  and 
intercostal  depressions  with  each  inspiration,  and  the  tense  and  rigid 
neck,  show  the  effort  of  the  inspiratory  muscles  to  overcome  laryngeal 
obstruction.  The  picture  of  air-hunger  is  marked  as  the  child  sits  up 
in  bed  or  restlessly  throws  himself  to  and  fro.  The  dyspnoea  is  increased 
by  the  child's  mental  excitement,  which  is  aggravated  by  the  panic  of 
the  household.  The  hastily  summoned  physician  may  arrive  in  time  to 
witness  these  symptoms,  but  must  frequently  be  content  with  a  history, 
the  child  having  fallen  asleep  after  vomiting  induced  by  domestic  reme- 
dies. He  may  show  little  evidence  of  the  recent  disturbance.  Occasion- 
ally, the  attack  is  prolonged  to  extreme  asphyxiation,  the  violent  muscu- 
lar effort  to  overcome  the  obstacle  to  inspiration  causing  pulmonary 
congestion  from  aspiration  of  blood.  The  superficies  are  pale  from 
depletion  of  their  vessels,  and  the  nails  and  lips  are  cyanotic  from 
venous  stasis  and  accumulation  of  C02.  Under  carbonic  acid  narcosis 
the  spasmodic  element  subsides,  with  immediate  relief  of  the  dyspnoea, 
which  is  followed  by  the  sleep  of  exhaustion.  If  the  inflammation  be  sub- 
glottic, however,  the  tumefaction  of  the  mucosa  and  adhesive  quality  of 
the  exudate  may  so  obstruct  the  larynx  as  to  prolong  the  dyspnoea,  so  that 
in  rare  instances  a  feeble  child  may  succumb.  Usually  the  following 
day  finds  the  patient  apparently  well,  although  the  second  and  even 
the  third  night  may  see  the  symptoms  repeated.  Rarely  for  several 
consecutive  nights  the  attacks  may  occur,  with  diminution  in  their 
severity. 


320  DISEASES    OF    THE    RESPIRATORY    TRACT 

Prognosis. — The  prognosis  as  to  recovery  is  good,  though  recurrences 
are  common  until  developmental  changes,  such  as  increased  amplitude 
of  the  larynx  and  stability  of  the  nervous  system,  diminish  the  suscepti- 
bility. 

Treatment. — The  treatment  in  a  mild  case  requires  little  more  than 
keeping  the  bowels  free,  application  over  the  larynx  of  turpentine  and 
lard,  and  spraying  the  nares  and  pharynx  with  Seller's  solution  several 
times  a  day.  It  may  not  be  necessary  to  keep  the  child  in  bed  unless 
to  prevent  exposure,  but  the  temperature  of  the  room  should  be  even. 
The  air  should  be  moistened  by  evaporation  of  water  to  which  a  drachm 
(3.75  C.c.)  of  eucalyptol,  thymol,  or  tincture  of  benzoin  has  been  added. 
Warm  drinks  should  be  frequently  given  and  the  child  should  even  be 
roused  for  a  drink  of  warm  milk  during  the  night. 

Night  attacks  of  stridor  may  sometimes  be  averted  by  syrup  of 
ipecac  in  small  doses,  two  to  fifteen  minims  (0.12-0.90  C.c.)  during 
the  day  and  two  doses  of  the  mixed  bromides  of  sodium  and  ammonium, 
two  to  ten  grains  (0.13-0.65  Gm.),  according  to  age,  an  hour  before  and 
at  bedtime. 

In  severe  attacks  the  dyspnoea  may  be  relieved  by  emesis  induced  by 
teaspoonful  doses  of  syrup  of  ipecac,  repeated  every  fifteen  to  thirty 
minutes.  If  necessary,  this  may  be  followed  by  two  to  five  grain  (0.13- 
0.32  Gm.)  doses  of  powdered  alum  in  a  teaspoonful  of  sugar  and  by 
copious  draughts  of  warm  water.  In  rare  instances  of  failure  to  secure 
emesis  the  stomach  should  be  emptied  by  the  stomach-tube.  Hot  fomen- 
tations should  be  applied  over  the  larynx.  In  older  children  an  ice-bag 
may  be  substituted.  The  bowels  should  be  evacuated  by  an  enema,  and 
calomel,  in  small  repeated  doses,  is  useful. 

If  the  glottic  spasm  persist,  bromides,  five  to  ten  grains  (0.32-0.65 
Gm.),  according  to  age,  with  one  to  ten  grains  (0.065-0.65  Gm.)  of 
chloral  .may  be  administered  per  rectum,  and  repeated  if  necessary  in 
an  hour.  Opium  in  the  form  of  camphorated  tincture,  five  to  twenty 
minims  (0.3-1.25  C.c.)  maybe  given  to  quiet  the  nervous  excitement. 

Protracted  dyspnoea  with  increasing  cyanosis  may  require  intuba- 
tion of  the  larynx.  If  ineffectual,  on  account  of  oedema  of  the  glottis,  a 
rare  complication  in  acute  laryngitis,  tracheotomy  may  be  necessary. 

CHRONIC   LARYNGITIS. 

Chronic  laryngitis  is  usually  the  outgrowth  of  repeated  attacks  of  the 
acute  catarrhal  form,  with  resultant  permanent  congestion  and  hyper- 
plasia of  the  mucous  membrane.  It  is  a  frequent  accompaniment  of  ton- 
sillar and  adenoid  enlargements  or  of  hypertrophic  rhinitis.  It  is  un- 
doubtedly aggravated  by  and  may  be  due  to  mouth  breathing.  Syphilis 
and  more  rarely  tuberculosis  are  also  causes  of  chronic  laryngeal  in- 
flammation. 

The  whole  mucosa  in  chronic  catarrhal  laryngitis  is  hyperEemic, 
the  vocal  cords  may  be  thickened  and  their  surfaces  show  erosions 
which  occasionally  result  in  shallow  ulcers.     The  thickening  often  ex- 


CHRONIC    LARYNGITIS  321 

tends  to  the  neighboring  tissues,  interfering  with  the  pliability  of  the 
epiglottis. 

From  habitual  huskiness  the  voice  may  become  whispering  or  there 
may  be  complete  aphonia.  There  are  recurrent  exacerbations,  easily 
induced  by  fatigue,  dampness,  inhalations  of  smoke  or  dust,  or  by  vis- 
ceral disturbances  which  cause  congestion  of  the  upper  respiratory  tract. 
There  is  frequent  effort  to  clear  the  throat  by  "  hemming"  or  cough- 
ing, although  the  amount  of  expectoration  is  small. 

Hoarseness  in  early  infancy  is  always  suggestive  of  syphilitic  laryn- 
gitis and  may  be  present  in  the  first  week  of  life.  The  history  or  the 
presence  of  other  syphilitic  lesions  would  point  to  the  character  of  the 
laryngitis.  The  type  of  lesion  is  most  frequently  that  of  condyloma 
which  primarily  attacks  the  epiglottis.  It  can  sometimes  be  recognized 
without  the  use  of  the  mirror. 

Tuberculous  ulcers  may  appear  primarily  in  the  larynx.  This  is  very 
rare  in  early  childhood,  as  tubercular  lesions  in  this  locality  are  usually 
secondary  to  those  in  the  lungs.  These  ulcers  give  rise  to  pain  which 
is  constant  and  severe,  in  addition  to  the  other  symptoms  of  laryn- 
gitis. They  are  usually  accompanied  by  some  rise  of  temperature,  gen- 
eral malnutrition,  and  indications  of  tuberculosis  in  other  areas. 

Prognosis. — Chronic  laryngitis  is  not  a  self-limiting  disease  and  may 
prove  extremely  refractory  to  treatment.  The  catarrhal  cases  usually 
recover  after  removal  of  adenoid  growths  or  correction  of  other  disorders 
of  nose  and  pharynx. 

Treatment. — Mild  alkaline  and  antiseptic  solutions  may  be  sprayed 
into  the  pharynx  so  that  nebulized  liquid  may  reach  the  laryngeal  mucosa. 
In  the  same  way  diluted  astringent  solutions,  as  nitrate  of  silver,  pro- 
targol,  or  sulphate  of  zinc,  may  be  used  (Formula  13). 

Aside  from  the  removal  of  adventitious  growths  in  the  nose  and 
pharynx,  hygiene  is  the  most  potent  factor  in  the  treatment  of  chronic 
laryngitis.  Correction  of  gastric,  hepatic,  or  renal  disorders  may  be 
required,  also  avoidance  of  all  known  causes  of  laryngeal  irritation. 
Since  the  symptoms  are  ameliorated  during  the  warm  season,  removal 
from  a  damp,  changeable  climate  to  one  that  is  dry  and  more  equable 
offers  the  most  promising  results. 

SYPHILITIC   LARYNGITIS. 

The  prognosis  in  syphilitic  laryngitis  is  better  in  children  than  in 
adults,  as  the  lesions  are  usually  more  superficial  and  less  destructive. 
Stenosis  from  cicatricial  contractions  may  require  intubation,  in  which 
case  the  tube  may  have  to  remain  in  situ  for  several  months.  Antisyphil- 
itie  treatment  in  the  form  of  mercurial  inunctions  and  potassium  iodide 
must  be  continued  until  the  disappearance  of  all  symptoms. 

TUBERCULOUS   LARYNGITIS. 

The  general  treatment  of  tuberculous  laryngitis  should  be  that  of 
tuberculosis.     In  addition  to  the  cleansing  sprays,   the   pain  may  be 

21 


322  DISEASES    OF    THE    KESPIRATORY    TRACT 

alleviated  by  the  use  of  anodyne  solutions,  such  as  cocaine,  menthol, 
adrenalin,  etc.  (Formula  17). 

PSEUDOMEMBRANOUS  LARYNGITIS — MEMBRANOUS  CROUP;     TRUE   CROUP. 

Pseudomembranous  laryngitis  is  an  inflammation  of  the  larynx  char- 
acterized by  the  formation  of  a  false  membrane  which  may  involve  the 
epiglottis  and  supracordal  tissues,  or  it  may  be  wholly  confined  to  the 
subglottic  mucosa.  Whatever  be  its  location,  the  pseudomembrane  forma- 
tion in  the  larynx,  as  on  other  mucous  surfaces,  is  due  to  bacteria.  Among 
the  micro-organisms  most  commonly  found  are  the  Klebs-Loeffler  bacillus, 
pseudodiphtheria  bacillus,  and  the  strepto-,  pneumo-,  and  staphylococcus. 
Analysis  of  a  large  number  of  cases  of  membranous  laryngitis  showed 
Klebs-Loeffler  bacilli  to  be  present  in  about  eighty  per  cent.  Pseudomem- 
branous laryngitis  may  occur  as  a  primary  affection,  but  is  more  fre- 
quently secondary  to  diphtheria  of  the  nose,  tonsils,  or  pharynx.  The 
pseudomembrane  shows  no  structural  peculiarities  characteristic  of  the 
etiologic  microbe.  Its  extent  varies  in  different  cases  and  it  may  involve 
the  entire  trachea  and  even  the  smaller  bronchi  (Fig.  145).  It  may  be  so 
thick  as  to  diminish  greatly  the  lumen  of  the  larynx  or  it  may  appear  as 
an  extremely  delicate  deposit  on  the  mucosa,  so  that  symptoms  of  sten- 
osis may  be  only  exceptionally  due  to  the  blocking  of  the  larynx  by  the 
actual  membrane.  The  element  of  spasm  undoubtedly  operates  in  the 
majority  of  cases  in  the  causation  of  asphyxia. 

The  symptoms  of  primary  pseudomembranous  laryngitis,  aside  from 
obstructed  respiration,  are  rarely  severe.  The  temperature  seldom  rises 
above  101°  F.  (38.3°  C).  There  is  but  little  glandular  involvement,  as 
the  laryngeal  mucosa  is  poorly  supplied  with  absorbents.  Hoarseness 
and  cough,  which  mark  the  invasion,  increase  in  severity  as  the  disease 
progresses,  with  signs  of  dyspnoea  especially  seen  upon  inspiration. 
Later  the  expiration  shows  obstruction,  the  cough,  at  first  clanging, 
becomes  aspirant,  and  the  voice  is  reduced  to  a  whisper  or  there  is  com- 
plete aphonia. 

All  the  symptoms  of  respiratory  obstruction  described  under  catarrhal 
laryngitis  may  appear,  but  are  usually  more  gradual  in  their  develop- 
ment. Sleep  gives  but  temporary  relief  from  the  progressive  stenosis. 
The  condition  is  indicative  of  grave  danger  from  impending  asphyxia- 
tion in  which  the  disease  soon  terminates,  in  the  absence  of  prompt  relief. 
The  course  from  inception  to  fatal  termination  may  cover  a  period  of 
from  one  to  five  days. 

Diagnosis. — Membranous  croup  may  be  differentiated  from  foreign 
bodies  in  the  larynx  by  the  history,  sudden  onset,  and  absence  of  fever 
in  the  latter ;  from  retropharyngeal  abscess  by  the  character  of  the  cough 
and  the  presence  of  a  tumor  in  the  post-pharyngeal  wall.  From  catarr- 
hal laryngitis  the  differentiation  is,  at  times,  extremely  difficult,  but  as 
a  rule  the  onset  is  less  acute,  the  fever  less  marked,  the  development  of 
stenosis  more  gradual  and  progressive,  and  less  relieved  by  sleep,  the 
cough  is  less  frequent  and  noisy,  aphonia  is  more  common,  and  stridor 


'HEX.  ^ 


I 


Fig.  145.— Diphtheritic  membrane  from  trachea  and  bronchus,  coughed  during  intubation. 

(Dr.  S.  W.  Kellcy.) 


(EDEMA    OF    THE    GLOTTIS  323 

appears  both  in  inspiration  and  expiration  in  the  later  stage.  The 
bacterial  examination,  which  should  never  be  omitted,  will  in  this  form 
of  laryngitis  show  Klebs-Loeffler  bacilli  in  the  majority  of  cases.  As  the 
smear  can  rarely  be  secured  from  within  the  larynx,  culture  tests  must 
be  made  from  the  secretions  of  the  adjacent  mucosa.  Negative  findings 
do  not  disprove  the  existence  of  true  diphtheria. 

Treatment. — Every  case  should  be  isolated  and  treated  as  a  suspected 
case  of  diphtheria.  The  present  trend  of  opinion  favors  the  early  use 
of  antitoxin  in  full  doses  (4000  to  6000  units).  The  administration  of 
calomel,  ipecac,  and  soda  should  be  commenced  early  and  continued  until 
the  bowels  act  freely.  Rest  in  bed,  pure  air  warmed  to  from  70°  to  75°  F. 
(21°-24°  C),  and  moistened  by  evaporation  of  water  containing  tur- 
pentine, eucalyptol,  or  compound  tincture  of  benzoin,  with  entire  free- 
dom from  excitement,  must  be  secured.  The  diet  should  consist  of  warm 
liquids.  If  the  pulse  be  weak  and  rapid,  alcoholic  stimulants  and  strych- 
nia should  be  given.  For  respiratory  stenosis,  an  emetic,  such  as  ipecac 
or  alum,  may  be  tried  but  should  not  be  frequently  repeated.  Vapor- 
laden  air,  from  the  croup-kettle  or  water-pail  in  which  heated  bricks 
are  placed,  under  an  improvised  tent,  usually  relieves  the  dyspnoea  and 
may  be  repeated  as  often  as  beneficial.  During  these  inhalations,  the 
child  should  be  protected  from  the  moisture  by  a  blanket  or  rubber 
sheet. 

Mercurial  sublimations  are  sometimes  useful  and  may  be  adminis- 
tered under  the  tent  by  placing  fifteen  to  forty  grains  (1-26  Gm.)  of 
calomel  on  a  heated  surface,  as  a  fire-shovel  raised  to  a  red  heat.  This 
is  preferable  to  an  alcohol  lamp  on  account  of  safety.  The  room  should 
be  aired  after  each  sublimation,  which  may  be  repeated  every  three  or 
four  hours  if  beneficial.  The  air-hunger  renders  the  need  of  oxygen  too 
obvious  to  require  emphasis.  A  supply  of  fresh  warmed  air  should 
never  be  neglected,  and  the  can  of  oxygen  at  the  bedside  may  prove  of 
inestimable  value.  In  extreme  stenosis  intubation  of  the  larynx  may 
be  necessary  to  relieve  the  dyspnoea.  (See  Diphtheria.).  Uncompli- 
cated cases  which  escape  asphyxiation  tend  to  recovery  in  from  five  to 
seven  days. 

(EDEMA   OP    THE    GLOTTIS. 

(Edema  of  the  glottis  is  occasionally  the  cause  of  laryngeal  stenosis 
in  children.  The  infiltration  of  serum  occurs  chiefly  in  the  epiglottis 
and  aryepiglottic  folds.  The  loosely  attached  mucosa  becomes  at  times 
enormously  distended  and  presents  the  appearance  of  tense  pale  pink 
tumors.  Overhanging  the  glottis  they  approximate  at  each  inspiration, 
so  that  complete  occlusion  and  suffocation  may  result. 

This  much-dreaded  condition  may  be  caused  by  the  swallowing  of 
hot  liquids,  corrosive  acids,  or  alkalies,  or  by  the  inhalation  of  steam  and 
irritating  vapors.  It  is  an  occasional  complication  of  inflammations  of 
the  mucosa  of  the  pharynx  and  larynx,  or  of  perichondritis.  It  may 
accompany  scarlet  fever,  variola,  erysipelas,  diabetes,  etc.,  or  may  be 


324  DISEASES    OF    THE    RESPIRATORY    TRACT 

caused  by  the  irritation  of  a  foreign  body.  Rarely  it  appears  as  an 
angioneurosis  and  is  then  classified  as  an  idiopathic  oedema.  Most  fre- 
quently oedema  of  the  glottis  is  seen  as  a  grave  complication  of  diseases 
of  the  heart,  kidneys,  lungs,  and  liver,  and  it  may  be  the  terminal  con- 
dition of  extreme  hydremia. 

The  prominent  symptoms  are  inspiratory  dyspnoea — expiration  being 
unaffected- — stridor  and  cough.  The  voice  may  be  clear,  since  the  vocal 
cords  are  rarely  involved.  The  sensation  of  a  foreign  body  in  the  larynx 
leads  to  frequent  efforts  to  clear  the  throat  with  but  little  expectoration. 
If  due  to  local  inflammation  there  is  dysphagia  and  tenderness  on 
pressure  over  the  cricoid  cartilage.  If  the  oedema  develop  as  a  result  of 
remote  organic  lesion,  pain  is  not  a  prominent  feature. 

The  diagnosis  from  other  forms  of  laryngeal  stenosis  is  made  by 
direct  inspection,  laryngoscopic  examination,  or  by  palpation.  The 
cedematous  masses  may  sometimes  be  felt  with  the  finger. 

The  prognosis  of  oedema  of  the  glottis  is  grave  if  unrelieved. 

Treatment. — The  indications  are  for  derivation  and  local  depletion. 
For  the  first,  free  catharsis,  hot  foot-baths,  and  general  diaphoresis  are 
means  to  be  recommended.  Cold  applications  to  the  neck  and  the 
swallowing  of  cracked  ice  may  prove  beneficial.  Astringent  sprays, 
as  weak  solutions  of  tannic  acid,  alum,  cocaine,  or  adrenalin,  should 
be  used  locally.  All  conditions  tending  to  favor  local  infiltration 
shoukl  receive  appropriate  treatment.  Scarification  is  the  most  effica- 
cious procedure  for  local  depletion.  A  curved  bistoury,  wrapped  with 
adhesive  plaster  to  one-eighth  of  an  inch  of  the  point,  may  be  introduced 
over  the  epiglottis,  guided  by  the  index  finger  of  the  left  hand  which 
depresses  the  point,  so  that  it  engages  the  tumefied  mucosa  of  the  glottis. 
The  incisions  should  be  made  at  the  outer  borders  to  prevent  the  escaping 
blood  and  serum  from  entering  the  larynx.  In  extreme  dyspnoea  prompt 
tracheotomy  should  be  performed. 

TUMORS   OF    THE   LARYNX. 

Cough  and  steadily  increasing  dyspnoea,  which  persist  for  weeks 
or  months,  may  be  due  to  the  presence  of  new  growths  in  the  larynx. 
The  form  most  frequently  seen  in  chiklhood  is  that  of  papilloma, 
which  is  occasionally  met  with  in  very  young  infants  and  may  be 
congenital. 

These  growths  are  single  or  multiple,  sessile  or  pedunculated,  and 
are  generally  located  on  or  near  the  vocal  corols,  hence  interfering  with 
phonation.  The  most  frequent  site  is  the  anterior  commissure.  No 
definite  cause  for  these  tumors  is  known,  although  their  occurrence  in 
connection  with  warty  growths  in  other  parts  of  the  body  has  given  rise 
to  the  suggestion  of  a  "papillomatous  diathesis." 

The  symptoms  are  similar  to  those  of  chronic  laryngitis  with  possibly 
more  marked  tendency  to  aphonia  and  recurrent  attacks  of  asphyxia. 
The  history  shows  a  progressive  character.  The  diagnosis  from  chronic 
laryngitis  must  be  made  by  the  laryngoscope. 


TUMOES  OF  THE  LARYNX  325 

The  prognosis  as  regards  life  is  grave  in  infancy  as  there  is  a  ten- 
dency to  recurrence  after  removal.  Jn  this  resped  Laryngeal  papillomata 
prove  an  exception  to  the  rule  regarding  benign  tumors.  There  is 
danger,  especially  in  young  infants,  of  suffocation  from  mechanical 
obstruction  and  easily  induced  spasm  of  the  larynx.  The  growth  itself 
is  provocative  of  catarrhal  inflammation  and  renders  the  Larynx  espe- 
cially susceptible  to  diphtheritic  and  other  infectious  processes.  Fail- 
ures in  intubation  are  occasionally  due  to  narrowing  of  the  glottis  from 
the  presence  of  these  growths. 

The  treatment  is  surgical  in  the  removal  of  the  tumors  through  the 
mouth  by  means  of  specially  devised  instruments,  or  by  thyrotomy  or 
laryngotomy.  Occasionally  tracheotomy  must  be  performed  to  avert 
threatened  asphyxiation  from  spasm  or  from  engagement  of  a  peduncu- 
lated growth  in  the  chink  of  the  glottis. 

FOREIGN  BODIES  IN  THE  LARYNX   AND  TRACHEA. 

Foreign  bodies  of  great  variety  not  infrequently  have  found  their 
way  into  the  child's  larynx  through  accidental  aspiration.  This  is 
most  likely  to  occur  during  fits  of  coughing,  crying,  or  sneezing,  while 
holding  some  small  body  in  the  mouth,  or  during  the  mastication  of 
food.  Children  sleeping  with  some  object  in  the  mouth  are  liable  to  this 
accident,  as  during  sleep  the  glottis  is  relaxed.  Paralysis  of  the  laryn- 
geal muscles,  especially  after  diphtheria,  favors  the  entrance  of  substances 
through  the  chink  of  the  glottis.  They  may  lodge  in  the  ventricles, 
bringing  on  a  fit  of  coughing  by  which  they  are  expelled,  or  by  a  spasm 
of  the  glottis  they  may  be  retained  and  cause  alarming  symptoms  of 
suffocation.  Such  a  body  occasionally  passes  into  the  trachea  or  down 
into  the  right  bronchus,  where  it  may  become  impacted,  shutting  off  the 
air  from  the  right  lung. 

Lumbricoid  worms  sometimes  find  their  way  through  the  glottis.  At 
times  the  larynx  or  trachea  is  invaded  by  the  rupture  of  a  caseating 
gland  in  the  neighborhood. 

The  first  symptoms — cough,  dyspnoea,  and  aphonia — vary  greatly  with 
the  size  and  form  of  the  foreign  body  and  its  location.  Cough,  excited 
by  the  irritation,  is  usually  severe  and  prolonged  to  extreme  exhaustion. 
Occasionally  the  cough  and  dyspnoea  may  cease  for  hours,  only  to  return 
with  increased  intensity  when  the  body  is  dislodged  from  some  part 
where  it  was  temporarily  impacted.  Peas,  beans,  or  dried  cereals  may, 
by  swelling  from  absorption  of  moisture,  increase  the  dyspncea  and 
irritation.  Indestructible  substances,  as  beads,  coins,  etc.,  have  been 
known  to  remain  in  the  larynx  for  many  days  and  even  years  with  but 
little  disturbance.  Lodging  in  the  bronchus  they  may  cause  inflamma- 
tion and  ulceration,  and,  escaping  into  adjoining  tissue,  give  rise  to 
pneumonia,  pleurisy,  abscess,  or  emphysema.  Small  bodies  sometimes 
move  up  and  down  with  each  respiratory  excursion  and  may  be  heard 
by  auscultation  over  the  trachea,  rattling  against  its  walls.  If  impacted 
in  a  bronchus,  a  foreign  body  may  give  rise  to  pain  located  at  one  side 


326  DISEASES    OF    THE    RESPIRATORY    TRACT 

of  the  sternum,  while  the  respiratory  murmur  may  be  feeble  or  wanting 
in  that  lung. 

Diagnosis. — The  diagnosis,  although  usually  plain  from  the  history 
and  symptoms,  is  sometimes  difficult.  The  sleeping  child,  with  some 
small  body  in  his  mouth,  may  awaken  suddenly  with  all  the  symptoms 
of  acute  laryngitis,  and  occasionally  cases  have  been  treated  as  such 
even  to  tracheotomy,  when  the  cause  was  revealed  as  a  foreign  body 
in  the  larynx.  Antitoxin  has  been  administered  for  a  supposed  laryngeal 
diphtheria  which  proved  to  be  due  to  a  grain  of  popcorn  or  a  nut. 
Pertussis  which  baffled  all  remedies  for  months  has  terminated  with  the 
expulsion  of  a  small  coin.  The  X-ray  will  aid  in  the  location  of  a  body 
if  it  be  of  sufficient  density. 

The  prognosis  is  always  grave. 

The  indications  are  for  the  immediate  removal  of  the  foreign  body. 
Care  should  be  exercised  not  to  crowd  a  lodged  body  further  down 
the  larynx  by  rude  palpation.  If  the  substance  is  known  to  be  smooth 
and  symmetrical,  slapping  the  child  on  the  back,  while  suspended  with 
head  downward,  may  promote  dislodgement.  If  not  immediately  relieved 
the  child  should  be  placed  in  the  hands  of  a  specialist. 

TRACHEITIS. 

Tracheitis,  independent  of  inflammation  of  the  larynx  or  bronchi, 
is  rare  and  of  short  duration.  Its  involvement  in  a  general  respiratory 
catarrhal  inflammation  is  common.  Foreign  bodies,  if  long  retained, 
cause  tracheitis  of  varying  intensity,  and  occasionally  acute  catarrh  may 
have  its  beginning  in  this  tube. 

Among  the  symptoms  are  tickling,  burning,  or  pain  upon  the  inspira- 
tion of  cold  air,  as  well  as  some  tenderness  on  pressure  over  the  trachea. 
The  expectoration  is  not  as  profuse  as  is  that  of  bronchitis. 

The  diagnosis  from  bronchitis  is  not  easy,  although  a  sense  of  heat 
in  the  throat  or  behind  the  sternum,  in  the  absence  of  bronchial  rales, 
is  suggestive  of  tracheitis. 

The  treatment  of  acute  catarrhal  inflammation  of  the  trachea  is 
essentially  the  same  as  that  of  acute  bronchitis.  In  addition,  inhalations 
of  compound  tincture  of  benzoin,  eucalyptol,  or  terebene,  one  teaspoonful 
to  the  pint  of  boiling  water,  will  relieve  the  pain,  or  oily  sprays  may 
be  used. 

Diphtheritic  tracheitis  is  not  an  uncommon  sequel  of  laryngeal  diph- 
theria. Instances  are  known  in  which  the  false  membrane  developed  on 
the  tracheal  mucous  membrane  in  the  absence  of  laryngeal  diphtheria. 
Examination  of  the  sputum  revealed  the  presence  of  the  Klebs-Loeffler 
bacillus  when  diagnosis  from  clinical  symptoms  and  laryngoscopic  ex- 
amination failed. 

ACUTE  BRONCHITIS. 

Catarrhal  inflammation  of  the  mucous  membrane  of  the  large  and 
medium-sized  bronchi  is  more  frequent  in  childhood  than  in  later  life. 


ACUTE    BRONCHITIS  327 

The  explanation  for  this  frequency  is  seen  in  the  greater  prevalence  of 
causes,  both  predisposing  and  exciting.  Of  the  former  may  be  men- 
tioned some  of  the  anatomical  peculiarities  of  infancy,  also,  lowered 
vitality  resulting  from  malnutrition,  constipation,  dentition,  and  rhachi- 
tis.  Among  the  latter  are  the  infectious  diseases  and  greater  exposure 
to  chilling  of  the  surface. 

From  the  first  breath  until  late  childhood  the  lungs  are  physiologically 
congested.  As  compared  with  mature  development  the  ratio  of  alveolar 
to  tubular  capacity  is  less.  The  ratio  of  vascular  capacity  to  that  of 
the  right  heart  is  less,  so  that  the  lungs  are  relatively  overworked.  One 
evidence  of  this  appears  in  the  ratio  of  respiration  to  pulse-rate,  which 
is  less  than  in  later  life.  Anatomical  peculiarities  are  seen  in  the 
tortuosity  and  distensibility  of  the  pulmonary  blood-vessels,  the  loose 
attachment  of  the  bronchial  mucosa,  the  want  of  rigidity  of  the  thoracic 
parietes,  the  underdevelopment  of  the  respiratory  muscles,  and  the 
yielding  character  of  their  points  of  origin  and  insertion.  Since  active 
hyperemia  or  passive  congestion  are  commonly  recognized  as  preliminary 
to  acute  catarrhal  inflammations,  there  is  in  the  engorgement  of  the 
bronchial  mucosa  of  infancy  a  constant  predisposition  to  bronchitis.  The 
instability  of  the  circulation  through  imperfect  development  of  vaso- 
motor control  in  infancy  shows  the  pathological  effects  of  disturbances 
nowhere  better  than  in  the  already  surcharged  bronchial  and  pulmonary 
vessels.  As  the  development  and  persistence  of  all  catarrhal  processes 
are  favored  by  lowered  vitality,  the  well  known  tendency  of  the  develop- 
ing period — with  its  double  burden  of  metabolism — to  debility  from 
trifling  disturbances  helps  to  explain  the  frequency  of  bronchitis  in 
children. 

Rhaehitis,  a  disease  of  infancy,  shows  a  special  predisposition  to 
catarrhs  of  the  respiratory  tract  as  well  as  to  mechanical  defects  of  the 
chest  which  handicap  respiration. 

Bronchitis  is  a  common  accompaniment  of  the  acute  infectious  dis- 
eases, such  as  measles,  influenza,  pertussis,  typhoid  and  scarlet  fevers, 
and  is  occasionally  associated  with  fermentative  and  putrefactive  dis- 
orders of  the  digestive  tract.  It  is  usually  preceded  by  rhinitis,  pharyn- 
gitis or  tracheitis  and  bears  an  intimate  relation  thereto,  both  in  predis- 
position and  etiology.  "  Catching  cold"  is  the  commonest  explanation 
of  its  causation.  Children  are  especially  susceptible  to  lowered  tem- 
perature because  of  their  relatively  large  radiating  surface,  and  the 
large  percentage  of  blood  in  the  superficial  capillaries  exposed  to  sur- 
rounding influences.  The  helplessness  of  infants  during  the  creeping 
and  toddling  age,  their  exposui'e  to  drafts  and  the  chilling  effects  of  wet 
diapers  and  drool-soaked  clothing,  as  well  as  the  want  of  intelligence  in 
older  children  and  their  reckless  exposures  to  wet  and  cold,  are  among 
the  common  exciting  causes  of  bronchitis  in  childhood. 

The  etiologic  relationship  of  micro-organisms  to  bronchitis  is  the 
same  as  that  seen  in  catarrhs  of  other  mucous  tracts.  The  bacteria  found 
in  the  sputum  of  bronchitis  include  the  entire  flora  of  the  bronchial  tree. 


328  DISEASES    OF    THE    RESPIRATORY    TRACT 

Their  pathogenic  importance  increases  with  the  development  of  condi- 
tions favorable  to  their  multiplication  and  invasion  of  the  mucosa  through 
the  broken  or  attenuated  epithelium.  The  preponderance  of  this  or  that 
pathogenic  organism  in  a  given  case  of  catarrh  of  the  respiratory  tract 
may  depend  upon  the  form  of  organism  prevalent  in  the  community.  In 
this  way  different  epidemics  of  nasal,  pharyngeal,  or  bronchial  catarrhs 
are  frequently  attributed  to  different  micro-organisms.  It  should  not  be 
forgotten,  however,  that  most  epidemics  of  acute  catarrh  present  other 
common  etiologic  conditions,  such  as  atmospheric  humidity,  prevailing 
winds,  changeable  temperature,  and  malhygiene.  Although  distinguished 
bacteriologists  claim  to  have  isolated  a  specific  organism  in  the  micro- 
coccus catarrhalis,  mixed  infection  is  the  rule  in  all  inflammatory  pro- 
cesses of  the  respiratory  mucosa. 

Symptoms. — An  attack  of  acute  bronchitis  usually  develops  somewhat 
suddenly,  with  the  history  of  exposure  and  more  or  less  rhinitis,  pharyn- 
gitis, or  laryngitis.  Cough  is  a  common  and  early  symptom,  at  first 
dry,  irritating,  and  ineffectual.  There  is  always  some  elevation  of 
temperature  and  usually  more  or  less  malaise.  These  symptoms  may 
vary  in  degree  from  a  barely  perceptible  indisposition  to  a  state  of 
profound  hyperpyrexia  with  headache,  vague  myalgias,  and  pain  in  the 
chest,  especially  induced  by  coughing.  This  may  be  frequent  and  rack- 
ing. Infants  manifest  their  discomfort  by  restlessness,  irritability,  and 
thirst.  Constipation  is  a  frequent  precursor  and  accompaniment  of 
acute  bronchitis.  Loose,  green  stools,  however,  often  follow  an  out- 
break of  bronchitis  in  young  infants  and  have  been  attributed  to  gastro- 
intestinal infection  from  the  swallowed  sputum.  In  infants,  vomiting 
is  frequently  caused  by  fits  of  coughing,  so  that  the  child  may  actually 
lose  an  appreciable  amount  of  nourishment  in  this  way.  The  stage 
of  dry  cough  rarely  lasts  more  than  twenty-four  hours  and  is  succeeded 
by  the  stage  of  expectoration  in  which  the  cough  is  softened  by  the 
outpouring  of  mucus  into  the  tubes.  In  older  children  this  is  extruded 
at  the  termination  of  each  paroxysm.  Children  under  four  or  five  years 
of  age  almost  invariably  swallow  the  sputum. 

The  expectoration  is,  at  first,  a  scanty,  whitish,  viscid  mucus,  but 
rapidly  increases  in  quantity  and  becomes  yellowish,  mucopurulent,  and 
may  be  colored  by  dust  or  soot.  Acute  bronchitis  is  self-limited  and, 
if  uncomplicated,  runs  its  course  in  from  five  to  ten  days.  The  tempera- 
ture has  usually  reached  its  height— 101°  to  103°  F.  (38.3°-39.4°  C.)— the 
second  day  of  the  attack,  gradually  subsiding  to  normal  in  from  three 
to  five  days.  Acceleration  of  pulse  usually  keeps  pace  with  the  rise  in 
temperature,  but  increase  in  respiration  is  out  of  all  proportion  to 
either.  This  disturbance  of  pulse-respiration  ratio  is  characteristic  of 
acute  pulmonopathies  and  may  reach,  even  in  simple  bronchitis,  a  ratio 
of  two  to  one  instead  of  the  normal  three  or  three  and  one-half  to  one. 
This  hurried  respiration,  the  play  of  the  alae  nasi  and  the  presence  of 
cyanosis  are  indicative  of  a  severe  attack,  regardless  of  temperature. 
The  severity  of  the  attack  depends  largely  upon  the  size  of  the  tubes 


ACUTE    BRONCHITIS 

involved  in  the  inflammation.  If  this  be  confined  to  the  larger  tubes 
and  trachea,  the  bronchitis  is  mild  and  usually  of  short  duration,  although 
the  cough  may  be  severe  and  expectoration  profuse.  A  more  severe  type, 
however,  is  that  which  affects  the  medium-sized  tubes,  involving  the 
entire  thickness  of  their  walls.  In  this  form  there  is  intense  congestion 
with  rapid  exfoliation  of  epithelium,  in  places  denuding  the  mucous 
lining  to  its  basement  membrane.  The  tubes  often  become  blocked 
with  accumulations  of  inflammatory  exudate  made  up  of  epithelial 
debris,  leucocytes,  bacteria  and  pus. 

The  gravest  type,  and  one  which  occurs  most  frequently  in  infants 
because  of  anatomical  peculiarities,  is  bronchitis  of  the  capillary  tubes, 
which,  with  their  paucity  of  muscular  fibres  and  absence  of  ciliated 
epithelium,  are  anatomically  and  histologically  related  to  the  alveoli 
themselves.  So  that  the  old  terms  "capillary  bronchitis,"  and  "alveo- 
lar" or  "suffocative"  catarrh,  not  only  represent  this  clinical  picture, 
but  are  also  suggestive  of  the  pathological  processes  of  this  frequently 
fatal  disorder  of  infancy. 

In  a  mild  case  of  bronchitis,  inspection  shows  nothing  but  a  slightly 
increased  frequency  of  respiration.  In  severe  types  there  are  dyspnoea, 
cyanosis  and  recession  of  the  less  resistant  parts  of  the  chest  wall  during 
inspiration. 

Percussion  gives  unaltered  resonance,  and  auscultation  during  the 
first  stage  reveals  slight  exaggeration  of  normal,  puerile  respiratory 
sounds,  or  there  may  be  dry,  sonorous  or  sibilant  rales,  indicative  of 
an  altered  lumen  of  the  tubes  from  zones  of  irregular  congestion  of  the 
mucous  lining.  In  the  moist  stage  auscultation  reveals  many  rales  vary- 
ing in  character  and  distribution  according  to  the  consistency  and  loca- 
tion of  the  secretion.  A  few  rhonchi  only  may  be  heard  over  the  larger 
tubes,  and  these  rarely  may  be  limited  to  one  side  of  the  chest.  Coarse 
bubbling  or  purring  rales  indicate  fluidity  in  the  large  bronchi.  Crepita- 
tion imparted  to  chest  walls  may  be  felt  through  the  clothing,  and  is 
often  a  cause  of  anxiety  to  the  mother.  Fine,  moist,  or  subcrepitant 
rales  indicate  secretion  in  the  smaller  bronchi  and  are  heard  in  cir- 
cumscribed areas.  The  conductivity  of  the  infant  chest  and  the  thinness 
of  its  walls  render  the  medium  rales  audible  over  most  of  its  surface. 
The  occlusion  of  even  a  considerable  number  of  the  smaller  tubes  may 
not  appreciably  diminish  the  respiratory  murmur,  on  account  of  the 
transmissibility  through  infants'  lungs  of  the  exaggerated  respiratory 
sounds  from  the  unaffected  areas. 

Diagnosis. — Bronchitis  may  be  distinguished  from  acute  or  chronic 
affections  of  the  upper  respiratory  tract  and  from  cough  due  to  other 
causes  by  the  physical  signs, — i.e.,  by  the  presence  of  rales,  fremitus, 
character  of  cough  and,  in  older  children,  sputum.  Intensification 
of  symptoms  and  a  prolonged  high  temperature  should  lead  to  a  sus- 
picion of  bronchopneumonia. 

Prognosis. — The  prognosis  of  acute  uncomplicated  bronchitis  in  chil- 
dren is  usually  good,  although  that  accompanying  the  acute  infectious 


330  DISEASES    OF    THE    RESPIRATORY    TRACT 

diseases  not  infrequently  develops  into  a  bronchopneumonia.  Bronchitis 
in  young  infants  must  always  be  regarded  as  a  serious  disease,  on  account 
of  the  anatomic  and  physiologic  peculiarities  of  the  respiratory  appara- 
tus at  this  period,  and  the  tendency  to  development  of  the  capillary 
form.  Weakly  infants  not  infrequently  succumb  to  attacks  of  uncompli- 
cated bronchitis.  In  very  young  infants  there  may  be  persistence  in 
some  portions  of  the  lung  of  congenital  atelectasis ;  or  occlusion  of  some 
of  the  tubes  and  absorption  of  the  residual  air  may  result  in  collapse 
of  the  area  thus  cut  off  (acquired  atelectasis). 

Treatment. — The  indications  for  treatment  in  these  conditions  are 
the  maintenance  of  oxygenation  and  support  of  the  infant's  strength, 
as  death  is  due  to  exhaustion  and  asphyxiation.  In  the  very  beginning 
of  an  attack  the  intensity  of  the  pulmonary  congestion  may  sometimes 
be  diminished  by  revulsant  measures  which  cause  determination  of  blood 
to  other  areas.  Hence  the  use  of  purgatives,  hot-baths  and  rubefacients  to 
the  surface  and  extremities.  The  air  of  the  room  should  be  warm — 70°  to 
72°  F.  (21°-22.2°  C.)— and  moistened  by  the  evaporation  of  water  con- 
taining turpentine,  eucalyptol,  creosote  or  compound  tincture  of  benzoin. 
The  bowels  should  be  freely  opened  by  calomel,  ipecac,  and  bicarbonate 
of  soda,  or  a  full  initial  dose  of  castor  oil.  The  chest  and  trunk  in  young 
infants  should  be  masseed  with  warmed  camphorated  oil.  In  older 
children,  an  application  of  turpentine  and  lard,  one  to  four,  will  prove 
more  stimulating.  The  use  of  poultices  and  fomentations  in  acute  pul- 
monary inflammations  has  been  the  subject  of  much  discussion,  probably 
not  so  much  on  account  of  their  doubtful  efficacy,  but  because  of  the 
frequency  of  their  abuse  and  malapplication.  Few  practitioners  have 
failed  to  observe  the  beneficial  effect  of  a  properly  applied  warm  poultice. 
It  should  be  light,  warm,  and  made  to  cover  the  entire  chest,  and  must 
be  retained  in  place  without  undue  constriction  or  embarrassment  of 
respiratory  movements.  Poultices  are  contraindicated  in  conditions  of 
exhaustion  and  profuse  bronchorrhcea.  Except  in  the  hands  of  a  trained 
nurse  their  application  is  so  doubtful  that  the  careful  physician  may  well 
discard  the  routine  ordering  of  poultices.  A  rational  substitute  is  a 
jacket  of  cotton  between  layers  of  cheesecloth,  covered  by  protective 
tissue.  This  should  be  cut  to  fit  and  pinned  smoothly  about  the  thorax. 
If  the  temperature  be  high  in  the  early  stage,  spiritus  Eetheris  nitrosi, 
two  to  five  minims  (0.12-0.3  C.c),  or  liquor  ammonii  acetatis,  five  to 
twenty  minims  (0.3-1.25  C.c),  may  be  administered  every  two  to  four 
hours,  for  the  first  day  or  two.  The  food  should  be  restricted  to  a  mini- 
mum allowance  and  water  freely  supplied.  Older  children  should  receive 
only  liquid  food  and  that  warmed.  Copious  draughts  of  hot  carmina- 
tive teas  may  be  useful  to  promote  elimination.  Mild  cases  may  require 
nothing  further. 

In  the  moist  stage,  vigorous  infants  may  be  assisted  in  ridding  their 
tubes  of  profuse  secretions  by  the  timely  administration  of  an  emetic,  as 
the  syrup  of  ipecacuanha,  in  teaspoonful  doses.  The  use  of  expectorant 
and  cough  mixtures  is  so  frequently  abused  that  much  gain  in  the  aggre- 


CHRONIC    BRO.XCIIITIS  331 

gate  will  result  from  their  abandonment  in  young  children.  Cough  of 
sufficient  frequency  to  deprive  the  child  of  needed  rest  may  require 
bromide  of  sodium,  one  to  four  grains  (0.065-0.26  Gm.)  in  syrup  of  lac- 
tucarium,  fifteen  to  sixty  minims  (0.72-3.75  Gm.;,  according  to  ;i»v, 
every  three  hours.  If  obstinate,  relief  from  cough  may  be  secured  by  the 
use  of  heroine,  one  one-hundredth  to  one-fiftieth  grain  (0.0006-0.0013 
Gm.),  or  even  camphorated  tincture  of  opium,  in  moderate  doses,  not  too 
frequently  repeated.  Profuse  bronchorrhcca  which  threatens  life  by 
drowning  may  call  for  the  administration  of  atropine  or  belladonna  in 
doses  of  one  one-thousandth  to  one  five-hundredth  grain  (0.00006-0.00013 
Gm.)  of  the  former,  or  one  to  two  minims  (0.06-0.12  C.c.)  of  the  latter, 
to  check  secretion  and  sustain  respiration.  Emptying  the  trachea  and 
bronchi  may  be  aided  by  the  force  of  gravity.  Holding  the  child  with 
face  and  head  downward  during  a  fit  of  coughing  may  be  followed  by 
the  expulsion  of  a  considerable  quantity  of  mucus.  The  tendency  to 
hypostasis  in  tubular  catarrhs  of  infants  calls  for  a  frequent  change  of 
position  and,  although  sleeping  quietly,  the  child  should  be  turned  every 
hour  or  two. 

Cyanosis  demands  oxygen,  secured  by  free  ventilation  or  even  cylin- 
ders of  oxygen  by  the  bedside.  The  heart  should  be  sustained  by  the 
use  of  alcohol  and  strychnia. 

Accumulations  of  gas  in  the  stomach  and  bowels,  which  by  their  pres- 
sure embarrass  respiration,  must  be  relieved  by  enteroclysis,  massage, 
and  catharsis.  The  convalescence  from  a  severe  attack  of  acute  bronchitis 
should  receive  careful  attention,  as  there  is  a  marked  tendency  to  recur- 
rence upon  slight  exposure,  with  the  ever-threatening  danger  of  broncho- 
pneumonia, or  the  acute  attack  may  become  chronic. 

There  should  be  supervision  of  the  hygiene,  including  nutritious  food. 
The  administration  of  cod-liver  oil  in  the  winter  months,  and  of  tonics, 
such  as  quinine,  iron,  and  strychnia,  are  indicated.  When  a  paroxysmal 
cough  persists,  inhalations  of  creosote  are  recommended,  especially  at 
bedtime.  For  recurring  elevations  of  temperature  during  convalescence, 
carbonate  of  guaiacol,  one  to  three  grains  (0.065-0.20  Gm.),  with  sugar 
of  milk  or  in  capsule,  may  be  given  four  times  a  day. 

Delicate  children,  prone  to  pulmonary  disorders  and  those  in  whom 
there  is  a  tubercular  heredity,  may  require  change  of  climate  to  secure  the 
free  outdoor  exercise  essential  to  complete  recovery. 

CHRONIC   BRONCHITIS. 

Repeated  attacks  of  acute  bronchitis  may  result  in  the  chronic  form 
of  the  disease.  It  is  frequently  a  sequel  to  the  acute  bronchitis  of  per- 
tussis, measles,  influenza,  and  other  infectious  diseases.  All  conditions 
which  favor  mechanical  pulmonary  stasis  may  cause  chronic  bronchitis, 
such  as  heart  disease,  especially  mitral  incompetency  and  chronic  dis- 
orders of  the  kidneys,  liver,  and  stomach.  Children  of  rheumatic,  tuber- 
culous, and  lymphatic  diatheses  are  prone  to  chronic  bronchial  catarrhs. 
Chronic  bronchitis  is  particularly  common  in  rhachitis  and  in  children 


332  DISEASES    OF    THE    RESPIRATORY    TRACT 

of  persistent  lowered  nutrition.  Catarrhs  of  the  upper  respiratory  tract, 
and  especially  adenoid  vegetations,  often  lead  to  chronic  inflammation 
of  the  bronchi.  This  disease  is  the  usual  accompaniment  of  certain 
pathological  conditions  of  the  respiratory  apparatus,  such  as  pulmonary 
tuberculosis,  chronic  vesicular  emphysema,  asthma,  bronchiectasis,  and 
compression  of  the  lungs  from  chest  deformities  or  enlarged  bronchial 
and  mediastinal  glands. 

Symptoms. — The  symptoms  differ  from  those  of  the  acute  form  in 
the  frequent  absence  of  fever  and  general  malaise.  The  cough  is  less 
frequent,  occurs  often  in  paroxysms  resembling  pertussis,  and  is  usually 
most  troublesome  at  night  and  upon  waking  in  the  morning.  The  ex- 
pectoration of  older  children  varies  in  quantity  and  character  with 
the  accompanying  condition.  It  may  be  scanty,  white,  and  frothy,  or 
copious,  mucoid,  or  mucopurulent  and  fetid.  Damp  cold  weather  pre- 
cipitates an  exacerbation  which  may  continue  for  weeks,  until  the 
approach  of  warm  or  dry  weather.  Intervals  of  quiescence  of  several 
weeks  duration,  especially  during  the  summer  months,  may  precede 
another  attack. 

In  uncomplicated  chronic  catarrh  of  the  bronchi,  inspection  and  per- 
cussion may  give  negative  results.  The  auscultatory  signs  vary  from 
those  of  the  acute  form,  principally  in  the  diminution  or  subsidence  of 
rales  after  a  paroxysm  of  coughing  and  free  expectoration,  and  in  the 
reaceumulation  of  mucus  causing  a  reappearance  of  rales  modified  by 
the  viscidity  of  the  secretion  and  size  of  the  affected  tubes. 

Diagnosis. — Chronic  bronchitis  is  differentiated  from  coughs  of  re- 
flex origin  by  the  chest  signs  and  expectoration;  from  uncomplicated 
pertussis  by  the  absence  of  rales  and  the  history  and  course  of  the  latter 
disease;  from  tuberculosis  by  the  absence  of  fever  and  other  consti- 
tutional symptoms  peculiar  to  that  disease. 

Prognosis. — The  prognosis  of  uncomplicated  primary  bronchitis  de- 
pends upon  the  diathesis  and  -  environment  of  the  patient.  When  sec- 
ondary to  other  pathologic  conditions,  the  prognosis  must  share  that  of 
the  causal  disorder.  In  estimating  the  outcome  of  chronic  bronchitis, 
the  tendency  to  chronic  enlargement  of  the  bronchial  glands,  as  a  stand- 
ing invitation  to  tubercular  infection,  should  not  be  overlooked.  So,, 
also,  the  susceptibility  of  children  with  chronic  bronchial  catarrhs  to 
repeated  attacks  of  pneumonia  must  be  considered. 

Treatment. — The  treatment  should  be  addressed  to  the  predisposing 
and  underlying  causes  when  they  are  determinable.  Improved  environ- 
mental and  nutritional  hygiene,  with  the  exhibition  of  tonics,  such  as 
iron,  cod-liver  oil,  and  fresh  air,  are  usually  necessary.  For  the  bron- 
chial catarrh  a  few  medicinal  agents  have  proved  serviceable,  such  as 
potassium  iodide,  syrup  of  hydriodic  acid,  compound  solution  of  iodine, 
syrup  of  the  iodide  of  iron,  and  alkalies  or  alkaline  waters.  Creosote, 
guaiacol,  or  terebene  may  be  given  internally  or  by  inhalations. 

The  multiplicity  of  drugs  recommended ,  for  chronic  cough,  regard- 
less of  its  origin,  has  undoubtedly  resulted  in  much  harm  to  the  digestive 


BRONCHIECTASIS 

organs  and  consequent  impairment  of  nutrition.     The  long-continued 
use  of  opiates  and  anodynes  should  be  discouraged  for  obvious  reasons. 

FIBRINOUS   BRONCHITIS. 

A  curious  but  rare  form  of  bronchitis  is  that  in  which  the  expectora- 
tion shows  casts  of  the  bronchi,  even  of  the  smaller  tubes.  It  is  found 
at  all  ages,  although  very  rarely  in  infancy.  It  is  still  a  matter  of  doubt 
whether  these  macaroni-like  casts,  composed  of  fibrin  or  coagulated 
mucin,  are  the  result  of  a  true  fibrinous  exudate  or  are  formed  by  the 
coagulation  of  mucin  through  the  action  of  acid  forming  bacteria.  The 
casts  sometimes  contain  air-bubbles  and  float  in  water,  where  they  may 
be  disentangled  and  their  true  nature  revealed.  Masses  have  been  expec- 
torated which  showed,  when  unrolled,  a  perfect  cast  of  an  entire  bron- 
chus with  all  its  principal  branches.  This  form  of  bronchitis  is  distinct 
from  the  croupous  bronchitis  which  results  from  an  extension  of 
laryngeal  diphtheria  to  the  bronchial  tree.  The  symptoms  do  not  differ 
from  those  of  ordinary  acute  or  recurrent  bronchitis  except  in  severity 
of  dyspnoea  and  the  great  relief  following  expectoration.  Other  condi- 
tions, such  as  bronchiectasis  and  emphysema,  usually  accompany  the 
chronic  form  of  bronchitis,  and  its  relation  to  astlima  has  been  suggested 
not  only  by  the  presence  of  Charcot-Leyden  crystals  and  Curschmann's 
spirals,  but  from  reported  attacks  which  alternated  with  certain  skin 
eruptions. 

The  disease  has  a  recurrent  tendency  and  is  usually  accompanied  by 
febrile  symptoms  of  varying  intensity.  The  diagnosis  is  made  alone 
from  the  tube-casts  in  the  expectoration.  It  is  obstinate  in  character 
and  favors  the  development  of  pulmonary  adenitis  and  tubercular 
infection. 

The  prognosis  is  serious,  rather  because  of  the  possibility  of  depend- 
ent pathological  lesions,  such  as  pneumonia,  tuberculosis,  emphysema, 
and  bronchiectasis,  than  from  the  bronchitis  itself. 

The  treatment  by  inhalations  of  vaporized  lime-water  has  proved 
beneficial,  as  the  exudate  is  soluble  in  alkaline  solutions.  The  adminis- 
tration of  potassium  iodide  is  claimed  to  have  hastened  recovery  in 
some  instances. 

BRONCHIECTASIS. 

Dilatations  of  one  or  many  bronchial  tubes,  with  atrophic  or  hyper- 
trophic changes  in  their  walls  and  sclerosis  of  the  peribronchial  tissues, 
are  occasionally  seen  in  childhood  and  even  in  young  infants.  The  loss 
of  resiliency  in  these  sacculated  or  cylindrical  dilatations  allows  the 
accumulation  of  mucus  and  inflammatory  products  which  quickly 
undergo  decomposition  from  the  action  of  saprophytes  and  other  bac- 
teria. Fetid  breath,  paroxysmal  cough  and  copious  expectoration  of 
putrid  sputum,  result  from  the  emptying  of  these  cavities.  \Yhatever 
theory  as  to  the  origin  of  the  morbid  process  which  results  in  this  cavity 
formation  be  accepted,  the  clinical  histories  show  previous  existence  of 
bronchitis,  either  simple,  chronic,  or  as  an  accompaniment  of  measles, 


334  DISEASES    OF    THE    RESPIRATORY    TRACT 

or  some  other  infectious  fever.  The  bronchial  walls,  weakened  by- 
bronchitis  or  bronchopneumonia,  may  yield  to  unusual  intratubular 
pressure.  Undoubtedly  lowered  nutrition  or  systemic  disease  renders  the 
bronchial  tubes  less  resistant,  so  that  a  succeeding  attack  of  severe  per- 
tussis may  readily  precipitate  the  dilatation  of  the  bronchioles  from  the 
increased  air-pressure  during  the  paroxysms  of  coughing.  When  the 
collection  of  decomposing  secretion  has  become  established,  the  infection 
of  adjacent  or  even  remote  tissues,  with  general  systemic  disturbance,  is 
readily  explained. 

Symptoms. — The  symptoms  of  bronchiectasis  are  rarely  pathogno- 
monic. There  is  cough,  usually  paroxysmal,  occurring  most  frequently 
in  the  morning  or  upon  marked  change  of  position,  with  expectoration 
of  a  large  quantity  of  fetid  sputum.  This  is  occasionally  blood-stained, 
or  hemoptysis  may  occur.  In  very  young  children  who  do  not  expecto- 
rate, the  vomitus  shows  the  presence  of  the  mucopurulent  secretion  which 
has  been  swallowed.  More  or  less  dyspnoea  is  common,  dependent  upon 
the  extent  of  tubular  involvement  and  the  accompanying  vesicular  em- 
physema, or  collapse  of  adjacent  areas.  The  cough  may  be  strangling 
in  character  because  of  the  large  quantity  of  secretion.  After  free 
expectoration  the  dyspnoea  is  greatly  relieved  until  the  dilated  tubes 
refill. 

Advanced  cases  show  a  rise  of  temperature  indicative  of  toxaemia 
from  this  permanent  nidus  of  infection.  The  appetite  is  capricious  or 
fails  entirely,  and  the  child's  condition  is  one  of  increasing  debility  and 
developing  cachexia,  with  hectic  fever  and  night  sweats  suggestive  of 
pulmonary  phthisis.  Chest  deformity  from  recession  of  a  portion  of  the 
thoracic  wall,  clubbing  of  the  fingers  and  toes,  and  even  bony  enlarge- 
ment of  the  terminal  phalanges,  are  seen  in  severe  long-continued  cases. 
These  symptoms  are  usually  associated  with  some  degree  of  cyanosis. 

Among  the  physical  signs,  inspection  shows  diminished  movements  of 
the  chest,  which  may  be  increased  after  the  cavities  have  been  emptied. 
Percussion  may  yield  dulness  over  a  large  collection,  changing  to  reso- 
nance after  the  accumulation  has  been  discharged.  Resonance,  also,  over 
adjacent  emphysematous  areas  may  be  found.  Auscultation  gives  am- 
phoric breathing  over  an  empty  sacculation,  and  all  the  varieties  of  moist 
rales,  from  those  of  the  accompanying  bronchitis  to  large  gurglings. 

A  milder  degree  of  bronchiectasis  than  the  above  described  is  undoubt- 
edly much  more  common. 

Diagnosis. — Although  positive  diagnosis  is  rarely  possible,  this  con- 
dition should  be  suspected  in  children  who  expectorate  copiously  in  the 
morning  or  after  unusual  exertion.  The  sputum  may.  be  mucoid  or 
mucopurulent,  with  little  or  no  odor. 

The  diagnosis  of  severe  cases  from  pulmonary  tuberculosis  is,  in 
some  instances,  extremely  difficult,  and  must  be  made  chiefly  by  the 
presence  of  bacilli  in  the  sputum.  From  abscess  and  gangrene  of  the 
lungs,  the  history  of  slower  onset  and  the  absence  of  histologic  elements 
of  lung  tissue  in  the  sputum  may  establish  a  diagnosis.     An  empyema 


ASTHMA  335 

secondary  to  bronchiectasis  may  add  the  local  signs  of  the  former  to  the 
history  of  the  pre-existing  disease.  A  sacculated  empyema  or  a  lung 
abscess,  not  communicating  with  a  bronchus,  should  yield  pus  to  the 
exploring  needle,  non-fetid  in  character,  contra  to  that  of  a  purulent 
bronchiectatic  accumulation. 

Prognosis. — The  prognosis  of  marked  and  advanced  bronchiectasis 
is  grave,  although  the  mild  type  of  limited  dilatation  may  show  occa- 
sional tendency  to  spontaneous  recovery. 

Treatment. — The  treatment  includes  the  best  of  hygiene,  tonics,  and 
restoratives,  with  removal  to  a  dry  climate  and  life  in  the  open  air. 
Anodynes  and  cough  sedatives  are  contraindicated,  since  free  evacuation 
of  the  dilated  bronchi  should  be  encouraged.  This  may  be  promoted  by 
a  radical  change  of  posture,  even  to  inversion  of  the  patient  several 
times  a  day.  More  or  less  successful  attempts  to  correct  the  fetor  have 
been  made  by  inhalations  of  vapor  of  turpentine  or  creosote  in  boiling 
water.  For  internal  administration  guaiacol  carbonate  is  recommended 
in  doses  of  one  to  five  grains  (0.065-0.32  Gm.)  four  times  a  day,  in 
capsules;  or  creosote  in  from  one-fifth  to  one  minim  (0.01-0.06  C.c.) 
doses,  alone  in  capsule  or  in  combination  with  liquid  peptonoids,  may  be 
given.  Onions  and  garlic  should  be  eaten  freely  with  the  food,  or 
syrupus  allii,  in  doses  of  from  one  to  two  teaspoonfuls,  may  be  taken 
three  or  four  times  a  day.  These  latter  contain  a  volatile  oil  which  is 
eliminated  by  the  pulmonary  membrane. 

Modern  surgery  already  includes  bronchiectasis  in  its  lists  of  oper- 
able conditions.  The  percentage  of  recoveries  has  not  been  very  gratify- 
ing thus  far,  as  many  dangers  and  uncertainties  attend  the  operation, 
except  in  selected  cases. 

ASTHMA. 

Asthma  is  a  disease  of  all  ages  and  may  occur  in  the  youngest  infant. 
The  first  decade  of  life  is  claimed  to  furnish  one-third  of  the  whole 
number  of  cases.  The  period  of  adolescence,  however,  shows  a  consider- 
able diminution  in  the  susceptibility  to  asthma.  Regardless  of  all  the 
facts  brought  forward  to  substantiate  the  different  theories  as  to  the  true 
nature  of  asthma,  the  hypothesis  of  a  neurosis  suffices  to  carry  all  the 
clinical  phenomena  of  this  disorder. 

Asthma,  etiologically  remarkable  in  its  variety,  appears  in  infancy 
perhaps  most  frequently  as  a  reflex  neurosis  due  to  irritation  of  some 
portion  of  the  respiratory  tract;  hence  it  is  oftenest  seen  in  relation 
to  either  preceding  or  accompanying  bronchial  catarrh.  The  element 
of  heredity  is  undoubtedly  a  strong  predisposing  factor,  as  asthmatic, 
gouty,  and  neurotic  family  histories  are  secured  in  many  eases. 

Of  the  many  conditions  known  to  act  as  exciting  causes  of  asthmatic 
attacks  there  may  be  mentioned  rhinitis,  nasal  and  pharyngeal  growths, 
adenoids,  hypertrophied  tonsils,  bronchial  catarrh,  digestive  disturb- 
ances, intestinal  parasites,  eruption  of  the  teeth,  inflammation  of  the 
middle  ear,  malaria,  exposure  to  dampness,  and  the  inhalation  of  irri- 


336  DISEASES    OF    THE    RESPIRATORY    TRACT 

tating  substances.  As  a  result  of  the  last-named  cause  hay  fever  is 
probably  the  most  familiar  example. 

The  attack  may  come  on  suddenly,  without  premonitory  symptoms, 
or  it  may  develop  during  the  course  of  a  bronchitis.  The  characteristic 
feature  is  the  dyspnoea,  in  which  the  obstruction  occurs  in  expiration, 
which  is  prolonged  and  wheezing  in  character.  The  respirations  are 
slow,  with  complete  reversal  of  the  respiratory  rhythm, — expiration  being 
four  to  six  times  as  long  as  inspiration.  The  distress  and  air-hunger 
are  marked  in  severe  cases;  the  face  has  an  anxious  look,  is  pale,  and 
may  be  cyanosed,  as  the  child,  with  rigid  neck-  and  trunk-muscles,  braces 
himself  in  sitting  posture  and  labors  to  expel  the  excess  of  residual  air 
from  the  alveoli  and  tubes.  The  dyspnoea  differs  from  that  of  croup 
in  that  the  soft  parts  of  the  neck  and  chest  do  not  recede  on  inspiration, 
nor  is  phonation  much  affected,  although  the  child  may  refuse  to  talk 
and  may  even  refrain  from  crying  from  dread  of  the  increase  in 
dyspnoea. 

The  attacks  come  on  most  frequently  during  the  night  and  may  last 
from  a  few  hours  to  several  weeks.  In  the  latter  case  there  are  remis- 
sions and  exacerbations  of  varying  duration  and  intensity.  As  in  the 
adult,  the  day  during  which  the  child  is  apparently  in  normal  health 
is  followed  by  a  night  of  distressing  dyspnoea,  of  which  the  succeeding 
day  shows  no  signs.  These  attacks  may  recur  night  after  night,  until 
the  child  shows  evidences  of  exhaustion  from  loss  of  sleep  and  deficiency 
of  oxygen.  Occasionally  the  asthma  terminates  as  abruptly  as  it  devel- 
oped, and  there  may  be  no  repetition  for  weeks  or  months. 

In  young  infants  there  is  usually  more  or  less  fever,  although  in 
older  children  the  temperature  is  sometimes  subnormal,  and  cough  is  not 
a  constant  symptom,  yet  it  may  be  frequent  and  severe  if  the  attack  be 
accompanied  by  acute  bronchitis.  In  infants,  frequently,  the  clinical 
picture  is  that  of  severe  bronchopneumonia,  and  the  sudden  and  unex- 
pected subsidence  of  all  the  symptoms  may  be  the  first  intimation  of  the 
true  nature  of  the  attack.  Percussion  early  may  yield  slight  dulness,  to 
be  succeeded  later,  especially  in  older  children,  by  hyperresonance.  The 
character  of  the  chest-sounds  revealed  by  auscultation  in  a  well-devel- 
oped paroxysm  of  asthma  is  unmistakable.  They  consist  mostly  of  sibi- 
lant or  sonorous  rales,  more  or  less  musical  in  character,  in  great  variety 
of  pitch  and  intensity,  heard  all  over  the  chest  both  upon  inspiration  and 
expiration.  These  are  accompanied  quite  frequently,  in  young  children 
and  infants,  by  moist  rales.  The  chest  is  usually  distended  from  the 
excess  of  residual  air,  and  the  play  both  of  the  thoracic  walls  and  dia- 
phragm is  restricted,  while  the  respiration  may  be  accelerated  to  sixty 
or  seventy  per  minute.     Expiration  is  always  prolonged. 

Examination  of  the  sputum  in  older  children  shows  the  presence  of 
small  round  bodies  like  sago  grains  (pedes  de  Lcennec),  Curschmann's 
spirals,  Charcot-Leyden  crystals,  and  also  eosinophiles.  The  latter  are 
increased  in  the  blood  preceding,  during,  and  following  the  asthmatic 
attack,  with  or  without  leucocytosis,  and  may  reach  as  high  as  fifty  per 


ASTHMA  337 

cent,  with  an  average  of  from  eight  to  twenty  per  cent,  of  the  Leucocyte 
count.        t 

Asthma  is  rarely  fatal,  although  infants  occasionally  succumb  to  a  sin- 
gle attack.  The  post-mortems  show  no  anatomic  changes  in  the  respira- 
tory tract  to  indicate  the  cause  of  the  tumultuous  disturbance.  Asthma 
developing  in  infancy  or  childhood  may  continue,  in  recurring  paroxysms 
throughout  life.  An  interesting  phase  of  asthma,  seen  especially  in 
children  of  gouty  heritage,  is  the  alternation  of  asthmatic  seizures  with 
skin  eruptions.  Urticaria  is  occasionally  displaced  by  a  paroxysm  of 
asthma  and  reappears  upon  the  subsidence  of  the  dyspnoea,  to  be  fol- 
lowed again  by  another  asthmatic  attack.  These  urticarial  wheals  dis- 
appear from  the  integument,  but  may  reappear  upon  the  mucosa  of  the 
mouth,  pharynx,  larynx,  and  trachea,  to  the  limit  of  the  laryngoscopic 
view.  This  fact  seems  to  corroborate  the  angioneurotic  theory  of  asthma 
which  would  attribute  the  respiratory  obstruction  to  tumefaction  of  the 
bronchial  mucosa,  due  to  urticarial  wheals,  instead  of  the  spasmodic 
contraction  of  the  circular  muscular  fibres  of  the  bronchi,  as  claimed  by 
the  former  hypothesis. 

Diagnosis. — The  diagnosis  of  asthma  from  all  other  forms  of  dysp- 
noea is  made  from  its  abrupt  onset  and  termination,  the  prolonged 
expiration,  the  peculiar  characteristic  rales,  and  the  microscopical 
examination  of  the  sputum  and  blood.  Bronchial  or  true  asthma  is  to 
be  differentiated  from  false  asthma  or  dyspnoea  due  to  cardiac,  renal, 
or  thymic  causation. 

Treatment. — The  treatment  of  an  attack  of  asthma  in  childhood  is 
important,  not  only  on  account  of  the  distressing  dyspnoea,  but  because  of 
the  importance  of  interrupting  the  paroxysms  before  the  recurrent  habit 
is  firmly  established. 

The  exciting  cause  should  be  sought  and  removed  if  possible.  This 
may  necessitate  the  recognition  and  treatment  of  dyspepsia,  constipa- 
tion, intestinal  worms,  and  also  adenoids  or  other  disorders  of  the  upper 
respiratory  tract.  Nutrition  must  not  be  overlooked,  and  frequently  a 
course  of  tonics,  generous  diet,  and  cod-liver  oil,  with  fresh  air,  exercise 
and  cool  or  cold  bathing,  may  be  necessary  to  tone  up  the  general 
nervous  system.  The  gouty  diathesis  may  call  for  antilithics  and  alka- 
line waters.  Any  existing  bronchitis  should  receive  appropriate  treat- 
ment. 

The  paroxysm  of  asthma  may  yield  to  inhalations  of  the  fumes  of 
burning  nitre  paper  and  stramonium  leaves,  agents  which  enter  into  the 
composition  of  several  celebrated  asthma  cures  (Formula  27).  Inhala- 
tions of  steam  and  creosote,  thirty  drops  of  the  latter  in  a  pint  of  boiling 
water,  will  aid  in  relaxing  spasm.  In  extreme  cases,  where  life  is 
threatened  by  asphyxiation,  chloroform  may  be  used,  or  there  may  be 
given  ipecac,  one-tenth  to  one-twentieth  grain  (0.006-0.003  0111.1  with 
y^.  of  a  grain  (0.0003  Gm.)  of  nitroglycerin  every  half  hour  for  three 
or  four  doses.  This  is  especially  effective  if  bronchitis  be  present. 
For  paroxysms  that  begin  with  sneezing  or  evidences  of  rhinitis,  one  to 

22 


338  DISEASES    OF    THE    RESPIRATORY    TRACT 

three  minims  (0.06-0.18  C.c.)  of  adrenalin  chlorine  solution  (1  :  1000) 
may  be  applied  to  the  nasal  mucous  membrane,  or  a  smaller  dose  may 
be  given  hypodermically  and  repeated,  if  necessary,  every  two  hours 
for  four  or  five  doses.  Tincture  of  belladonna  or  its  alkaloid  may  be 
given  in  small  doses  every  two  hours,  from  one-half  to  two  minims 
(0.03-0.12  C.c.)  of  the  former  or  from  g-oVo  grain  to  y^  grain  (0.00003- 
0.00024  Gm.)  of  the  latter,  according  to  age,  until  it  produces  flushing 
of  the  face  and  dilatation  of  the  pupils.  This  should  occur  after  the 
second  or  third  dose.  Morphine  is  probably  the  most  efficient  agent  for 
the  relief  of  the  asthmatic  paroxysms,  but  for  obvious  reasons  it  should 
only  be  exhibited  as  a  last  resort.  Potassium  iodide  has  undoubted 
value  in  the  affection  and  should  be  given  in  doses  of  from  one  to  five 
grains  (0.065-0.32  Gm.)  four  times  a  day. 

The  principal  sequela?  of  prolonged  and  repeated  asthmatic  attacks 
are  pulmonary  emphysema  and  dilatation  of  the  right  heart. 

FIBRINOUS   PNEUMONIA — LOBAR   PNEUMONIA;     CROUPOUS    PNEUMONIA; 

PNEUMONITIS. 

Fibrinous  pneumonia  is  an  inflammation  of  the  lungs  due  in  a  large 
majority  of  cases  to  the  pneumococcus  (the  diplococcus  of  Fraenkel). 
This  organism  is  often  found  in  the  upper  air-passages  of  those  in 
perfect  health,  but  more  frequently  during  an  epidemic  in  house  or 
community. 

Pneumonia  is  found  at  all  ages  and  may  be  congenital,  the  foetus 
having  become  infected  through  the  placenta  of  a  pneumonic  mother, 
the  pneumococcus  being  found  in  pulmonary  secretion  and  blood  of 
both  patients. 

Lobar  pneumonia  is  not  as  frequently  reported  during  the  first  two 
years  of  life  as  after  that  period.  It  is  of  most  common  occurrence 
from  the  second  to  the  fifth  year,  after  which  its  frequency  diminishes 
until  the  tenth  year.  The  disease  predominates  in  boys  over  girls  in 
the  ratio  of  three  to  two. 

Since  the  pneumococcus  may  induce  primary  as  well  as  secondary 
inflammations  in  other  organs — as  endocarditis,  meningitis,  pleuritis, 
and  arthritis — it  is  probable  that  the  location  of  the  morbid  process  is 
subject  to  determining  causes  outside  of  the  infective  organism.  This 
supposition  is  strengthened  by  the  fact  that  all  individuals  exposed  to 
the  infection  do  not  develop  similar  lesions  and  many  escape  entirely. 
Exposure  to  sudden  chilling  of  the  surface  is  universally  recognized 
as  an  important  determining  cause.  In  this  country,  at  least,  there  is 
unanimity  of  observations  concerning  the  greater  prevalence  of  pneu- 
monia during  the  winter  and  spring  months.  Vital  statistics  from  a 
number  of  large  cities,  also  the  opinions  of  many  observers,  show  pneu- 
monia to  be  on  the  increase. 

Pathological  Anatomy. — The  pathologic  process  does  not  differ  from 
that  in  the  pneumonia  of  adults,  with  the  exception  that  in  younger 
children  the  proliferation  of  epithelium  and  transudation  of  cellular 


FIBRINOUS    PNEUMONIA  339 

elements  are  more  marked.  The  specific  lesion  in  pneumococcic  pneu- 
monia is  a  fibrinous  exudate  into  the  pulmonary  alveoli,  which  becomes 
choked  with  serum,  red  and  white  cells,  and  epithelial  debris  entangled 
in  fibrin  filaments.  Usually  an  entire  lobe  is  involved  in  the  morbid 
process,  which  has  given  rise  to  the  designation,  "  lobar  pneumonia," 
a  misleading  term,  since  only  a  portion  of  a  lobe  may  be  invaded.  The 
process  may  involve  more  than  one  lobe  on  the  same  or  opposite  sides 
of  the  chest.  Although  the  opinions  of  observers  vary  as  to  the  rela- 
tive frequency  of  the  involvement  of  the  different  lobes,  the  average 
from  a  large  number  of  reports  shows  a  slight  preponderance  of  the 
left  lower.  Next  in  order  of  frequency  is  the  right  upper,  and  then  the 
right  lower  lobe.  The  right  middle  and  left  upper  lobes  are  rarely 
the  seat  of  primary  infection.  The  younger  the  infant  the  more  fre- 
quent is  the  occurrence  of  upper  lobe  lesion.  The  involvement  of  an 
entire  lung  is  not  uncommon,  or  lobes  on  opposite  sides  may  be  affected 
simultaneously  or  successively.  In  fact,  the  inflammation  may  travel 
the  entire  circuit  in  successive  invasions,  which  follow  closely  the  reso- 
lution of  other  involved  portions. 

Pneumonia  runs  a  definite  course,  during  which  it  presents  four 
fairly  well  marked  phases.  The  first  stage  is  that  of  invasion,  in  which 
there  is  engorgement  of  the  alveolar  blood-vessels  with  transudation  of 
serum  into  the  air-cells. 

The  second  stage  is  that  of  red  hepatization,  and  shows  complete 
consolidation  of  the  area  involved,  whose  cut  surface  is  uniformly 
dark,  resembling  liver,  changing  to  brighter  red  when  exposed  to  the 
air.  The  alveoli  are  engorged  with  the  exudate  which,  protruding  on 
the  cut  surface,  presents  a  granular  appearance.  The  affected  portion 
of  the  lung  is  swollen  to  the  extent  of  full  expansion  and  shows  inden- 
tations on  its  outer  surface  from  pressure  of  the  ribs.  This  stage  lasts 
usually  from  two  to  five  days,  but  may  continue  much  longer, — in  rare 
cases  for  several  weeks. 

During  the  third  stage — gray  hepatization — the  lung  becomes  mot- 
tled gray  and  yellow  by  irregular  decolorization  from  the  disappearance 
of  the  blood  pigment  and  increase  in  the  leucocytes.  In  the  fourth 
stage,  resolution  follows  by  the  general  liquefaction  of  the  inflamma- 
tory products  in  the  air-vesicles  and  capillary  tubes.  Much  of  this  is 
absorbed  by  the  lymphatics  and  the  remainder  is  forced  into  the  bron- 
chioles, from  which  it  is  coughed  up.  Pus  corpuscles  may  be  numerous 
and,  if  suppuration  be  extensive,  abscesses  may  form.  Usually,  how- 
ever, the  liquefied  products  rapidly  disappear,  leaving  the  lung  struct- 
ures in  the  normal  condition. 

Symptoms. — Although  the  onset  of  pneumonia  is  usually  more  or 
less  abrupt,  the  symptoms  and  physical  signs  may  not  be  very  marked 
for  the  first  two  or  three  days.  In  fact,  the  typical  symptoms  of  the 
adult  type  may  be  masked  or  absent  until  late  in  the  attack.  In  in- 
fancy, especially,  this  disease  is  so  frequently  wrongly  diagnosed  as  to 
affect  its  reported  percentage  of  prevalence.     The  one  common  symptom 


340  DISEASES    OF    THE    RESPIRATORY    TRACT 

is  fever,  from  102°-107°  F.  (39°-41.6°  C).  A  preceding  chill  is  occa- 
sionally noted  in  older  children  and  rarely  a  convulsion  in  infants. 
Initial  vomiting  is  not  uncommon  and  is  occasionally  accompanied  by 
diarrhoea.  Cough  may  or  may  not  be  present,  and  depends  largely  upon 
the  extent  of  bronchitis.  Younger  children  and  infants  show  fretful- 
ness,  or  hebetude  with  somnolence  if  the  temperature  be  high.  Ano- 
rexia, thirst,  and  coated  tongue  usually  accompany  the  fever.  There 
is  proportional  acceleration  of  the  pulse,  which  is  usually  full  and  sus- 
tained, but  may  be  weak.  The  most  significant  symptom  and  one  rarely 
absent  is  increased  respiration.  There  is  a  characteristic  change  in  the 
pulse  ratio  which  may  be  three,  two  and  one-half,  or  only  two  to  one, 
instead  of  the  normal  three  and  one-half  or  four  to  one.  The  play  of 
the  alas  nasi  with  inspiration  is  nearly  always  present,  varying  in 
degree  with  the  extent  of  lung  crippled.  Expiration  is  frequently 
accompanied  by  a  short  terminal  moan,  or  a  sharper  expiratory  grunt 
if  much  pleurisy  be  present.  The  face  is  usually  congested,  may  be 
deeply  flushed,  occasionally  cyanotic,  rarely  pale,  and  its  expression 
may  indicate  pain  or  preoccupation,  according  to  the  amount  of  dys- 
pnoea or  stupor.  Herpes  about  the  mouth  and  nose  is  commonly  seen  in 
pneumonia.     The  eyes  are  usually  heavy  and  lustreless. 

The  cough,  which  is  generally  present,  is  short,  dry,  and  restricted, 
the  latter  on  account  of  the  pain  which  it  induces.  More  or  less  con- 
stant pain  is  present,  and  in  young  children  this  is  often  referred  to 
some  portion  of  the  abdomen  or,  in  fact,  to  any  part  which  shares  in  the 
distribution  of  the  lower  intercostal  nerves.  Occasionally  this  pain  is 
pleuritic  and  is  located  over  the  affected  area.  In  infants  palpation 
of  the  abdomen  will  elicit  pain,  probably  from  upward  pressure  of  the 
displaced  viscera. 

The  temperature— 102°  to  105°  F.  (39°-40.5°  C.)— develops  early  and 
continues  throughout  the  attack.  Slight  daily  remissions  of  one  or  two 
degrees  are  the  rule.  Cases  in  which  the  temperature  rose  to  107°  F. 
(41.5°  C.)  have  been  reported.  Seven  days  is  the  average  course  of 
pneumonic  fever,  although  the  crisis  may  rarely  occur  on  the  third  day, 
and  occasionally  is  delayed  to  the  fifteenth  day  or  even  later.  The  tem- 
perature fall  is  abrupt.  In  from  six  to  twenty-four  hours  it  reaches 
the  normal  or  even  two  or  three  degrees  below.  In  children  especially 
the  crisis  of  pneumonia  may  be  preceded  by  a  rapid  defervescence, 
after  which  it  again  rises  to  its  former  height.  This  false  or  pseudo- 
crisis  is  followed  a  day  or  two  later  by  a  permanent  subsidence, — a  true 
crisis.  This  pseudocrisis  may  occur  twice  or  even  three  times  before  the 
real  crisis  is  reached,  and  may  cause  confusion  in  the  practitioner's 
mind  and  lack  of  confidence  in  his  diagnosis,  especially  if  the  pul- 
monary signs  be  masked. 

This  defervescence  by  crisis  is  almost  pathognomonic  of  fibrinous 
pneumonia,  occurring  in  older  children  quite  regularly  and  in  about 
seventy-five  per  cent,  of  younger  children,  although  in  infants  lysis  by 
remissions  of  temperature  is  quite  common.     With  the  subsidence  of 


FIBRINOUS    PNEUMONIA  341 

fever  the  pain  subsides,  cough  becomes  moist,  and  the  expectoration, 
which  before  was  scanty  or  wanting,  becomes  more  abundant  in  older 
children.  The  sputum  changes  from  a  glairy,  mucoid,  or  rusty  mate- 
rial, to  a  mucopurulent  character,  and  may  be  darkened,  by  blood 
("prune  juice"). 

The  pulse  is  reduced  in  frequency,  slowing  down  to  fifty  beats  per 
minute  in  extreme  cases,  but  it  may  become  irregular,  rapid,  and  weak. 
The  respirations  also  follow  the  temperature,  although  rarely  reaching 
normal  until  after  complete  resolution.  Return  of  febrile  symptoms 
always  indicates  a  fresh  invasion  of  the  pneumonia  or  some  complication, 
such  as  pleurisy  or  other  inflammation. 

From  the  very  beginning  of  the  attack  the  signs  of  prostration  are 
quite  marked.  Even  in  cases  of  moderate  severity  the  child  is  willing 
to  go  to  bed.  With  high  temperature  the  somnolence  may  approach 
coma  or  there  may  be  headache,  cervical  rigidity,  delirium,  tremors, 
and  other  symptoms  simulating  meningitis. 

The  physical  signs  to  one  unfamiliar  with  pneumonia  in  infancy 
are  often  misleading.  Inspection  occasionally  shows  diminished  re- 
spiratory movements  on  one  side,  especially  in  the  infraclavicular 
region. 

In  infants  and  young  children  percussion  may  fail  to  outline  the 
inflamed  area  by  dulness,  because  of  the  limited  extent,  deep  situation 
of  the  lesion,  resonance  of  overlying  healthy  lung,  or  tympanitic  exten- 
sion from  the  gas-distended  abdominal  viscera. 

In  the  infant,  local  hyperresonance  on  percussion,  with  high  tempera- 
ture, cough,  and  characteristic  disturbance  of  pulse  and  respiration, 
should  suggest  a  pneumonic  consolidation  in  some  other  portion  of  the 
lung.  Repeated  examinations  will  usually  show  a  circumscribed  area  of 
dulness,  even  in  young  infants,  although  this  sign  may  be  elusive  during 
the  first  three  or  four  days  of  the  attack.  Careful  auscultation  may 
locate  the  pneumonia  by  diminution  of  respiratory  murmur  over  a 
limited  area,  while  other  parts  of  the  chest  may  show  exaggerated 
sounds.  Mixed  rales  indicative  of  the  accompanying  bronchitis  are  fre- 
quently present.  Later,  the  area  of  consolidation  may  reveal  some- 
what tubular  breathing  with  subcrepitant  rales,  although  the  crepitant 
rales  of  invasion  are  rarely  heard.  Vocal  resonance  may  be  increased 
and  fremitus  from  crying  may  be  occasionally  distinguished  by  careful 
palpation.  It  is  significant  of  pneumonia  that  children  rarely  cry 
lustily,  because  of  the  pain  and  dyspnoea  incident  to  deep  inspiration. 
The  area  of  cardiac  dulness  is  increased  in  the  third  right  interspace 
from  engorgement  of  right  heart  due  to  pulmonary  obstruction,  and 
may  extend  two  finger-breadths  to  the  right  of  the  sternum.  The  pul- 
monic second  sound  is  greatly  accentuated  for  the  above  reason, 
although  it  should  not  be  forgotten  that  a  moderate  degree  of  accen- 
tuation is  normal  in  infancy.  The  spleen  may  be  enlarged  and  palpable, 
while  in  severe  right  heart  distention  the  area  of  hepatic  dulness  is 
notably  increased. 


312  DISEASES    OF    THE    RESPIRATORY    TRACT 

The  urine  shows  the  high  color,  increased  specific  gravity,  and  acid 
concentration  peculiar  to  febrile  disorders.  Following  the  crisis  the 
amount  of  urine  is  greatly  increased  and  for  a  day  or  two  contains  a 
considerable  amount  of  uric  acid  and  urates. 

Blood. — The  blood  findings  of  most  practical  value  in  pneumonia 
relate  to  the  variations  in  the  number  of  white  corpuscles.  Leucocytosis 
is  the  rule  in  this  disease  and  is  usually  most  marked  at  the  time  of 
crisis,  when  it  is  generally  regarded  as  a  favorable  symptom.  The 
diminution  of  leucocytes  after  the  crisis  is  abrupt  and  may  aid  in  differ- 
entiating between  the  occurrence  of  real  and  pseudocrisis.  A  persistence 
or  recurrence  of  leucocytosis  is  suggestive  of  a  new  invasion  or  compli- 
cation of  the  pneumonic  process.  The  interpretation  of  a  leucopenia 
must  depend  upon  the  attending  conditions.  If  accompanied  by  high 
temperature  and  increase  in  general  symptoms,  it  is  of  grave  prognostic 
importance ;  whereas  with  mild  symptoms,  leucopenia  may  be  merely 
indicative  of  a  very  mild  type  of  infection.  Although  in  pneumonia  the 
increase  in  white  cells  is  seen  chiefly  in  the  polymorphoneuclear  neutro- 
philes.  in  children  there  may  be  marked  increase  in  the  lymphocytes.  It 
is  claimed  that  Fraenkel's  pneumococcus  is  present  in  the  blood  of  all 
cases  of  fibrinous  pneumonia  and  may  be  demonstrated  in  the  centrifu- 
gate  if  a  large  quantity  of  blood  be  examined.  In  one  drop,  however,  the 
majority  of  the  examinations  will  fail. to  reveal  its  presence.  It  is  con- 
sidered that  the  abundance  of  these  organisms  in  the  blood  bear  a  direct 
relation  to  the  gravity  of  the  disease. 

The  course  of  fibrinous  pneumonia  in  childhood  is  atypical  in  a  ratio 
inversely  to  age;  hence  the  terms  wandering,  recurring,  of  short  dura- 
tion, central,  massive,  cerebral,  abdominal,  with  delayed  resolution,  and 
mixed. 

Clinical  evidence  points  to  abortive  pneumonia  as  not  of  infrequent 
occurrence.  It  is  possible  that  many  cases  of  f  ebricula  in  children  are  due 
to  an  aborted  pneumonic  invasion.  It  is  probable  that  in  many  of  these 
cases  the  infection  is  overwhelmed  before  exudation  is  complete,  as  the 
expectoration  after  defervescence  is  characteristic  of  alveolar  involve- 
ment, although  the  entire  period  of  febrile  movement  may  not  exceed 
forty-eight  or  even  twenty-four  hours.  Of  a  different  nature,  however, 
is  the  pneumonia  of  exceptionally  short  duration  (two  to  four  days),  in 
which  all  the  phenomena  of  a  typical  course,  from  initial  vomiting  to 
crisis  and  resolution  or  fatal  termination,  have  been  observed.  Eecurring 
pneumonia  is  simply  a  repetition  of  the  inflammatory  process  in  the  same 
area,  while  wandering  or  creeping  pneumonias  are  merely  successive  in- 
vasions of  different  areas. 

Central  pneumonia  is  particularly  interesting  because  of  the  frequent 
absence  of  physical  signs  and  pain  owing  to  the  deep  situation  of  the 
lesion.  Although  suspected,  this  form  of  pneumonia  may  be  impossible 
of  diagnosis  in  the  absence  of  typical  blood  findings  and  sputum.  Tem- 
perature crisis,  after  a  period  of  cough  and  accelerated  respiration,  is 
very  suggestive  of  a  deep-seated  pneumonia. 


PNEUMONIA  343 

The  term  massive  has  been  applied  to  a  pneumonia  in  which  the 
alveolar  exudates  overflow  into  smaller  bronchial  tubes  with  resultant 
physical  signs  of  enlarged  area  of  dulness  and  absence  of  respiratory 
murmur.  Cerebral  pneumonia  is  a  misnomer,  the  outgrowth  of  cerebral 
symptoms  which  not  infrequently  accompany  pneumonia  in  children, 
from  the  well-known  fact  that  the  cerebral  functions  are  readily  affected 
in  persistent  high  temperature,  active  hyperemia,  mechanical  stasis,  or 
any  acute  toxaemia.  Pneumococcic  infection  is  an  occasional  cause  of 
meningitis  which  may  occur  either  separately  or  in  connection  with 
pneumonitis. 

The  term  abdominal  pneumonia  has  arisen  from  the  occurrence  of 
abdominal  symptoms,  as  pain  in  different  localities,  for  reasons  pre- 
viously stated,  and  also  from  the  not  uncommon  accompaniment  in 
children  of  digestive  disturbances. 

Prolongation  of  the  attack  far  beyond  the  usual  period  may  occur  in 
weakly  children  and  marasmic  infants,  in  which  the  temperature  decline 
is  by  lysis.  In  other  cases,  frequently  in  robust  children  in  which  crisis 
occurred  at  the  end  of  the  usual  period,  physical  signs  of  consolidation 
persist  sometimes  for  weeks  or  months,  although  the  child  may  eat  well, 
put  on  flesh,  and  suffer  no  discomfort,  save  that  incident  to  curtailment 
of  respiration.  The  recovery  of  the  affected  lung,  although  delayed,  may 
be  complete  in  every  respect. 

The  typical  symptoms  of  a  fibrinous  pneumonia  may  be  masked  by 
a  coincident  catarrhal  pneumonia.  Atypical  pneumonias  are  reported 
in  which  the  pneumococcic  infection  is  reinforced  by  streptococcic,  as 
from  a  middle-ear  disease,  or  Friedlancler 's  bacillus.  During  epidemics 
of  influenza,  pneumococcic  pneumonias  may  be  modified  by  infection 
with  the  Pfeiffer  bacillus. 

Complications  and  Sequelce. — Next  to  bronchitis,  which  almost  always 
accompanies  pneumonia,  pleurisy  is  the  most  frequent  complication.  It 
usually  appears  over  the  parietal  surface  of  the  affected  lung,  where 
the  pneumonic  process  is  most  superficial,  as  a  fibrinous  exudate  or  dry 
pleurisy.  In  many  cases  it  occasions  but  a  small  transudation  of  serum 
in  the  pleural  cavity.  The  layer  of  exudate,  however,  may  be  thick  and 
pultaceous,  occluding  the  lumen  of  the  aspirating  needle  so  as  to  render 
exploratory  puncture  negative.  Empyema  not  infrequently  develops, 
in  which  the  pneumococcus  is  found  in  pure  culture  in  a  large  per- 
centage of  cases.  It  may  be  suspected  in  instances  where  dulness  over 
the  affected  side  persists,  with  an  increase  in  leucocytosis,  after  the 
crisis  of  the  pneumonia,  although  there  may  not  be  the  barrel-shaped 
distention  seen  in  large  pleuritic  effusion. 

In  ratio  of  frequency  inversely  to  age  of  patient,  as  a  complication 
in  fibrinous  pneumonia,  is  otitis  media.  In  a  majority  of  these  the  otitis 
is  purulent  and  examination  of  the  pus  will  show  the  diplococcus  pneu- 
monia?. 

Pericarditis,  as  a  complication,  occurs  more  frequently  in  left-sided 
pneumonia,  and  is  usually  of  the  fibrinous  or  exudative  type.     Charac- 


344  DISEASES    OP    THE    RESPIRATORY    TRACT 

teristic  friction  sounds  are  usually  obscured  by  those  of  the  accompany- 
ing pleuritis,  or  by  the  adventitious  respiratory  ^sounds  from  the  lung. 
If  the  pericardium  be  the  seat  of  an  extensive  effusion,  the  heart  by 
counterpressure  against  the  consolidated  lung  may  be  displaced  to  the 
right.  Unfortunately,  increase  in  dulness  to  the  right  of  the  sternum 
is  so  frequently  indicative  of  right-heart  distention  as  to  render  differ- 
entiation difficult  or  impossible.  However,  a  weak  pulse,  diffuse  and 
indistinct  apex  pact,  and  evidences  of  sudden  impairment  of  the  heart's 
action,  should  give  a  clue  to  pericarditis  with  effusion. 

Of  more  frequent  occurrence  as  a  complication  is  endocarditis  of  the 
left  heart,  which  may  be  malignant.  The  gravity  of  the  prognosis  is 
correspondingly  increased.  The  possibility  of  infective  emboli  from  this 
source  greatly  adds  to  the  complication,  and  diminishes  the  chances  of 
recovery. 

Rare  complications  of  pneumonia  occur  in  the  forms  of  peritonitis, 
arthritis,  and  nephritis.  A  suppurative  cellulitis  occasionally  develops 
from  metastasis  of  the  infection. 

Meningitis  may  precede  or  complicate  fibrinous  pneumonia,  with  or 
without  suppurative  otitis  media.  This  complication,  although  rare, 
occurs  most  frequently  in  infants  and  young  children,  and  must  be  dis- 
tinguished from  the  cerebral  symptoms  of  pneumonia  due  to  hyper- 
pyrexia and  altered  circulation  of  the  meninges.  Cerebrospinal  or  epi- 
demic meningitis,  due  to  pneumococcic  infection,  may  complicate  or 
follow  fibrinous  pneumonitis.  This  pneumococcus  of  Fraenkel  has  been 
found  quite  frequently  as  the  causative  agent  in  epidemic  meningitis 
during  the  prevalence  of  the  former  disease. 

A  recurrence  of  vomiting,  convulsions,  delirium,  coma,  or  opisthoto- 
nos, would  indicate  the  development  of  this  complication.  Lumbar  punc- 
ture and  examination  of  the  cerebrospinal  fluid  will  aid  in  the  diagnosis. 

Among  the  sequela?,  abscess  and  gangrene  of  the  lung  are  the  most 
important.  Owing  to  the  difficulty  of  differentiation  from  empysema 
these  are  usually  first  diagnosed  at  the  post-mortem. 

Pulmonary  fibrosis  or  interstitial  pneumonia  is  an  occasional  sequel 
and  will  be  discussed  under  that  subject. 

Diagnosis. — Fibrinous  pneumonia  may  be  diagnosed  by  the  sudden 
onset  with  chill,  vomiting,  convulsions,  disturbed  pulse-respiration  ratio, 
cough,  expiratory  moan,  or  grunt,  the  usual  physical  signs  when  present, 
and  continuous  high  temperature  ending  in  crisis.  It  is  confirmed  by 
the  examination  of  the  rusty  sputum  in  older  children  and  by  marked 
leucocytosis  which  disappears  with  crises. 

Prognosis. — The  prognosis  of  uncomplicated  fibrinous  pneumonia  in 
children,  after  the  second  year,  is  more  favorable  than  in  adults.  Infants 
under  that  age  bear  pneumonia  badly,  the  mortality  rate  being  from 
twenty  to  forty  per  cent,  in  strong  infants,  and  higher  in  the  cachectic 
and  poorly  nourished.  Among  conditions  which  favor  the  prognosis  in 
children  may  be  mentioned  their  freedom  from  organic  renal,  arterial, 
and  cardiac  lesions,  to  which  may  be  added  the  active  recuperative 


PNEUMONIA  345 

metabolism  of  the  developing  period.  The  extent  of  the  lung  lesion 
bears  less  constant  relation  to  the  mortality  than  the  persistence,  beyond 
eight  or  ten  days,  of  abnormally  high  temperature.  The  virulency  of 
the  infective  agent  undoubtedly  has  great  influence  on  the  mortality,  as 
it  is  well  known  that  the  death-rate  varies  with  different  epidemics,  re- 
gardless of  the  method  of  treatment. 

Treatment. — For  a  self -limited  disease  running  a  definite  course  of 
short  duration,  with  a  tendency  to  recovery  without  damaging  lesions, 
pneumonia  has  been  the  subject  of  much  overtreatment.  A  specific 
treatment  is  not  known  and  probably  never  will  be  until  a  pneumococcic 
antitoxin  is  discovered.  Those  at  present  advocated  have  proved  of 
doubtful  efficiency,  and  the  subject  of  antipneumonococcic  serum  must 
still  be  considered  in  the  experimental  stage.  If  certain  conditions  obtain 
during  an  attack  of  pneumonia  which  threaten  the  structural  or  func- 
tional integrity  of  vital  organs,  measures  for  relief  are  indicated. 
Among  the  urgent  conditions  are  overdistention  of  the  right  heart  from 
obstruction  to  the  pulmonary  circulation;  interference  with  respiratory 
movements  in  the  crippled  lung  by  pressure  from  overdistention  of  ab- 
dominal viscera,  or  from  the  weight  of  external  applications,  or  con- 
stricting clothing;  passive  cerebral  hyperemia  from  venous  stasis  in 
the  lesser  circulation ;  interference  with  normal  metabolism  from  dim- 
inution in  the  quantity  of  inspired  oxygen  and  accumulation  of  toxins 
in  the  blood  from  diminished  elimination. 

As  a  rule,  in  the  early  part  of  an  attack  of  pneumonia  the  bowels 
should  be  freely  opened  by  calomel  combined  with  ipecac  and  soda  (For- 
mulas 24  and  25),  small  doses  every  hour  until  free  catharsis  is  se- 
cured. If  this  be  delayed  beyond  the  tenth  or  twelfth  dose  it  may  be 
aided  by  one  or  two  teaspoonfuls  of  castor  oil  or  a  full  dose  of  mag- 
nesium citrate.  This  treatment  may  be  profitably  repeated  at  intervals 
of  a  few  days  throughout  the  course  of  the  disease.  The  stomach  and 
bowels  should  be  kept  free  from  gaseous  distention  by  careful  attention 
to  the  frequency  of  feeding  and  the  quantity  and  quality  of  the  food. 
This  in  older  children  should  be  concentrated  and  liquid,  given  in  small 
amounts.  In  the  nursling,  half  or  more  of  his  food  should  be  replaced 
by  water.  In  fact,  water  should  be  freely  supplied  to  the  pneumonia 
patient,  except  where  there  is  marked  evidence  of  right  heart  engorge- 
ment. Gastric  flatus  contra  indicates  food  until  relieved.  Sulphocarbolate 
of  soda,  a  grain  (0.065  Gm.)  for  each  year  of  age.  in  repeated  doses,  is 
sometimes  valuable.  Hot  carminative  infusions,  as  of  peppermint,  anise. 
or  gaultheria,  may  prove  useful.  Intestinal  gas  is  best  relieved  by  high 
enemata  of  normal  salt  solution  or  soapy  water  containing  milk  of  asa- 
fetida  or  a  few  drops  of  turpentine.  Since  it  is  known  that  the  mucosa 
of  the  upper  respiratory  tract  swarms  with  pathogenic  bacteria,  fre- 
quent applications  of  alkaline  and  antiseptic  solutions  should  be  used  by 
swab  and  atomizer  to  cleanse  these  areas  (Seller's  or  Dobell's  solution). 

The  call  for  oxygen  must  be  met  by  a  free  supply  of  pure  air  admitted 
from  outdoors  for  the  sole  use  of  the  patient  and  nurse.     In  extreme 


346  DISEASES    OF    THE    RESPIRATORY    TRACT 

cases  pure  oxygen  from  the  can  may  be  used  to  increase  the  supply.  In 
hyperpyrexia  the  temperature  of  the  room  need  not  be  kept  at  the  ordi- 
nary sick-room  standard  so  long  as  the  patient's  extremities  are  kept 
warm.  It  is  a  common  error  to  burden  the  pneumonia  patient  with 
blankets  and  to  close  the  windows  and  doors  to  the  admission  of  air 
from  fear  of  draughts.  In  prolonged  high  temperature — 104°  to  106° 
F.  (40°-41°  C.) — with  restlessness  and  delirium,  improvement  follows 
sponging  with  tepid  water  and  alcohol  (3  to  1)  for  five  to  fifteen  min- 
utes. This  may  be  repeated  as  often  as  necessary.  Antipyretic  drugs 
are  rarely  indicated,  and  usually  do  more  harm  than  good.  Quinine  and 
tincture  of  iron  throughout  the  attack  are  advocated  by  many  physicians 
of  wide  experience.  The  effect  on  the  stomach  and  the  bitter  taste  of 
quinine  are  obstacles  to  its  use  in  young  children.  An  aqueous  solution 
of  the  bisulphate  of  quinine,  five  to  ten  grains  (0.3-0.65  Gm.)  may  be 
administered  by  rectum,  if  considered  sufficiently  important.  Inunc- 
tions of  quinine  and  lard,  or  lanolin  (1  to  8)  may  be  applied  freely  to 
the  surface  of  the  body  with  massage.  Organic  iron  preparations,  as  the 
peptonates,  are  most  eligible  for  young  children.  In  older  children  the 
American  tincture  of  the  chloride  may  be  preferred  for  the  antiseptic 
action  of  its  hydrochloric  acid.  The  official  mixture  of  iron,  quinia,  and 
strychnia  presents  a  happy  combination  when  the  last-named  drug  is 
indicated. 

Cough  and  pain  frequently  deprive  the  little  patient  of  rest,  so 
essential  for  the  maintenance  of  strength,  in  which  case  analgesic  and 
sedative  measures  may  be  required.  The  triple  bromide  mixture,  sodium, 
potassium,  and  ammonium,  one-half  grain  (0.003  Gm.)  of  each  for  each 
year  of  age,  in  syrupus  lactucarii  (Aubergier's),  fifteen  to  forty  minims 
(0.9-25  C.c.)  may  be  sufficient.  Persistent  pain  may  require  larger 
doses  or  even  the  exhibition  of  codeine,  one-tenth  grain  (0.006  Gm.), 
to  a  child  three  to  five  years  of  age;  Dover's  powder,  one  grain  (0.06 
Gm.),  or  even  morphine  hypodermically.  This  latter  agent  should  be 
used  with  great  caution  and  only  in  the  earlier  days  of  the  illness.  Its 
fairly  earned  reputation  for  mischief  is  due  to  maladministration  after 
the  patient  has  become  exhausted,  and  when  the  depressed  respiratory 
function  is  easily  overwhelmed.  It  is  especially  important  that  the 
strength  of  the  patient  be  preserved  during  the  early  days  of  the  attack, 
hence  the  demand  for  sedation  at  the  only  period  in  which  it  is  com- 
patible with  safety.  Diuresis  should  be  encouraged,  if  necessary,  by  the 
administration  of  spiritus  mindereri  in  from  one-quarter  to  two  drachms 
(1-8  C.c.)  closes,  repeated  every  two  or  four  hours  as  necessary,  or 
enteroclysis  of  normal  salt  solution  once  or  twice  every  twenty-four 
hours.  Applications  to  the  chest,  as  a  routine  treatment,  are  of  doubtful 
utility  and  in  many  instances  are  harmful.  Many  physicians  employ 
ice-bags  over  the  area  of  lung  lesion  as  soon  as  that  is  determined.  With 
this  object  in  view,  they  auscultate  and  percuss  industriously,  several 
times  daily,  for  the  earliest  evidences  of  localization.  In  skilful  hands, 
it  is  believed  much  may  be  accomplished  in  the  way  of  limiting  the 


BRONCHOPN  B I MONIA  317 

extent  of  the  pneumonic  process  by  this  early  application  of  ice-bags. 
Their  indiscriminate  or  careless  use  may  expose  the  patient  not  only  to 
much  discomfort  but  to  considerable  risk  of  injury  from  refrigeration. 
The  prejudice  against  blood-letting  is  so  strongly  entrenched  that  its 
advocacy  is  likely  to  arouse  an  opposition,  well  fortified  in  physiologic 
theories,  regarding  the  value  of  each  drop  of  the  life-sustaining  fluid. 
Independent,  however,  of  the  question  of  the  relation  of  hamiic  condi- 
tions to  the  inflammatory  process,  it  may  be  safely  asserted  that  for 
purely  mechanical  reasons  a  little  blood  may  be  profitably  withdrawn 
when  the  right  heart  is  overdistended.  For  this  purpose  two  to  six 
leeches  may  be  applied  to  the  right  hepatic  region  whenever  the  line  of 
cardiac  dulness  advances  two  or  more  finger-breadths  to  the  right  of  the 
sternum  in  the  fourth  interspace.  Irregular  heart  action  and  very 
marked  accentuation  of  the  second  pulmonic  sound,  accompanied  by 
rapid  and  feeble  pulse,  may,  during  the  pyrexia,  call  for  digitalis,  in 
which  case  the  tincture  in  doses  of  three  to  six  minims  (0.18-0.36  C.c.) 
may  be  given  to  a  child  of  eight  years,  and  repeated  every  three  or  four 
hours. 

Pulmonary  engorgement,  with  or  without  cyanosis,  is  sometimes  re- 
lieved by  the  hot  bath  or  by  stimulating  rubefacients  applied  over  the 
thorax.  At  the  crisis,  cardiac  stimulation  is  most  frequently  indicated, 
and  at  this  time  strychnia  and  alcohol,  with  or  without  digitalis,  are 
most  serviceable.  The  dose  of  the  former  should  be  sufficient  to  produce 
decided  tonic  effect  on  the  heart  and  may  be  rapidly  advanced  from  one 
two-hundredth  of  a  grain  (0.00033  Gm.)  in  infants  to  one-sixtieth  or 
one-fortieth  of  a  grain  (0.001-0.0015  Gm.)  in  a  child  of  eight  years,  and 
repeated  every  three  hours.  Alcohol,  in  the  form  of  good  whiskey  or 
brandy,  may  be  given  in  teaspoonful  doses  in  milk  every  two  to  four 
hours.  Artificial  warmth  to  the  body  should  be  supplied  at  the  period 
of  crisis. 

In  delayed  resolution,  the  indications  are  to  maintain  the  strength 
of  the  patient  and  to  be  on  the  alert  for  complications.  In  the  ordinary 
uncomplicated  fibrinous  pneumonia  a  frequent  use  of  the  placebo  may 
be  necessary. 

BRONCHOPNEUMONIA — CATARRHAL    PNEUMONIA  :     LOBULAR   PNEUMONIA  : 
CAPILLARY   BRONCHITIS. 

Bronchopneumonia  is  essentially  a  disease  of  infancy  and  early  child- 
hood. It  is  infrequent  after  the  sixth  year  and  rare  in  adults.  The  age 
of  most  frequent  occurrence  is  the  first  two  years  of  life.  This  form  of 
pneumonia  is  never  a  primary  disease,  but  is  always  secondary  to  a 
bronchitis,  hence  its  name. 

In  its  multiplicity  of  pathologic  forms  the  one  common  lesion  is  a 
bronchiolitis  (capillary  bronchitis),  the  inflammation  involving  the  entire 
thickness  of  the  tubular  walls  and  extending  more  or  less  into  the  sur- 
rounding tissue  (peribronchitis).  In  this  way  not  only  the  adjacent 
alveoli  are   included   in  the   inflammation   but   also   the   terminal   air- 


348  DISEASES    OF    THE    RESPIRATORY    TRACT 

vesicles  by  direct  extension  of  the  morbid  process  along  the  smaller 
tubes.  The  bronchioles  are  occluded  by  an  accumulation  of  mucus,  epi- 
thelial cells,  and  bacteria,  while  the  blood-vessels  of  the  alveolar  septa 
are  engorged  and  the  air-spaces  filled  with  mucopus,  epithelium,  leuco- 
cytes, and  occasionally  a  small  amount  of  fibrin.  The  paucity  or  absence 
of  fibrin  and  the  common  occurrence  of  bronchiolitis  and  peribronchitis 
are  the  distinguishing  features  of  bronchopneumonia  as  compared  with 
fibrinous  pneumonia.  The  lesions  of  bronchopneumonia  may  be  limited 
to  circumscribed  areas  including  but  one  or  a  few  bronchioles  and  adja- 
cent lobules  with  intervening  areas  of  normal  or  emphysematous  lung 
tissue.  By  extension,  these  inflammatory  areas  may  coalesce  so  as  to 
involve  an  entire  lobe.  A  cut  section  of  the  affected  lobe  may  show 
coincident  and  in  close  proximity  different  inflammatory  stages,  such  as 
congestion,  red  and  gray  hepatization,  and  resolution,  interspersed  with 
areas  of  atelectasis,  vesicular  emphysema,  and  dilated  bronchial  tubes. 
Where  the  pneumonic  areas  approach  the  surface  of  the  lung  the  over- 
lying pleura  is  congested,  showing  darker  colored  depressions  from  col- 
lapsed lobules,  and  is  either  lustreless  or  covered  by  a  plastic  exudate. 
This  pleuritis  may  result  in  cohesion  of  layers  or  an  accumulation  of 
serum  or  pus  in  the  pleural  sac.  Bronchopneumonia  is  usually  bilateral 
and  found  in  the  lower  lobes  or  occasionally  in  the  posterior  portions  of 
the  upper  lobes.  The  apices  generally  show  compensatory  emphysema 
in  proportion  to  the  extent  of  the  lower  lobe  involvement. 

Etiology. — Infancy,  marasmus,  rhachitis,  syphilis,  lymphatism,  poor 
hygiene,  climate,  season,  infectious  diseases,  exposure  to  cold,  and  the 
aspiration  of  blood,  food,  or  other  foreign  substances,  are  among  the 
chief  predisposing  causes.  The  infectious  diseases,  in  order  of  fre- 
quency, are  bronchitis,  measles,  influenza,  diphtheria,  typhoid  and  scar- 
let fevers.  The  exciting  causes  may  be  one  or  more  of  a  variety  of  the 
infectious  organisms  commonly  present  in  the  nose,  mouth,  or  pharynx, 
which  have  become  pathogenic  in  the  lowered  resistance  of  the  dis- 
ordered bronchial  mucosa. 

Of  all  the  causes  of  death  during  the  first  two  years  bronchopneu- 
monia is  assigned  in  from  seventeen  per  cent,  in  private  practice  to  forty 
per  cent,  in  institutions.  The  susceptibility  of  infants  to  bronchitis  (the 
common  precursor  of  bronchopneumonia)  has  been  discussed  on  page 
327.  The  clinical  fact  that  young  infants  and  children,  or  those  weak- 
ened by  previous  disease,  are  the  subjects  of  bronchopneumonia,  while 
the  more  favored,  rugged,  and  older  children  develop  fibrinous  pneu- 
monia, finds  some  explanation  in  a  series  of  experiments  conducted  by 
Dr.  A.  "Wadsworth.* 


*  Animals  were  inoculated  with  pneumonia  exudates  of  varying  degrees  of 
virulence  with  the  following  results:  In  the  normal  animals  a  virulent  exudate 
caused  a  bacteriamiic  type  of  infection  without  much  lesion  of  the  lungs;  when  less 
virulent  matter  was  used  no  lesion  appeared  in  the  lungs.  In  animals  previously 
subjected  to  trauma,  cold,  and  the  injection  of  irritating  substances,  the  inoculation 


BK( )  X  CHOP  N  EUMO  X I A  349 

The  occurrence  of  bronchopneumonia  with  gastro-enteritis  may  add 

to  the  explanation  of  its  frequency  during  a  period  when  the  latter  dis- 
ease is  most  prevalent.  That  bronchopneumonia  is  not  as  strictly  con- 
fined to  the  months  of  inclcmcnl  weather  as  is  fibrinous  pneumonia  may 
be  due  to  the  fact  that  its  predisposing  conditions  and  precursory  dis- 
orders prevail  at  all  seasons  of  the  year.  In  older  children  broncho- 
pneumonia rarely  occurs  except  as  an  accompaniment  or  sequel  of  the 
acute  exanthems  previously  mentioned.  In  this  case  the  exciting  micro- 
organism is  most  frequently  that  of  the  pre-existing  disease,  usually 
associated  with  the  pneumococcus  of  Fraenkel. 

Of  a  large  number  of  bacterial  studies  of  bronchopneumonia  the  pneu- 
mococcus was  found  alone  in  more  than  fifty  per  cent,  and  was  associated 
with  other  bacteria  in  twenty-five  per  cent.  Of  other  organisms,  alone  or 
associated,  were  found  the  streptococci  and  staphylococci  and  bacilli  of 
Friedlander,  Klebs-Loeffier,  coli  communis,  and  tuberculosis. 

Symptoms. — The  symptoms  of  bronchopneumonia  vary  so  widely  in 
different  cases  that  this  disease  may  be  said  to  have  no  fixed  type.  The 
same  wide  variation  is  true  also  of  the  physical  signs,  which  may  be 
absent  entirely,  so  that  the  pneumonia  may  be  overlooked  or  its  symp- 
toms attributed  to  the  disease  to  which  it  is  secondary.  The  onset  may 
be  abrupt  or  gradual;  there  may  be  hyperpyrexia  or  the  temperature 
may  show  little  if  any  rise  throughout  the  attack ;  cough  may  be  absent, 
slight,  or  frequent  and  distressing.  There  may  be  fretfulness,  restless- 
ness, delirium,  or  apathy,  somnolence,  and  stupor.  Probably  the  most 
usual  form  of  development  is  seen  in  the  intensification  of  all  the  symp- 
toms during  an  attack  of  bronchitis  from  which  the  infant  may  have 
suffered  for  several  days.  The  temperature  rises  to  103°  or  104°  F. 
(39.5°-40°  C.)  with  morning  (rarely  afternoon)  remissions  of  one  to 
three  degrees.  The  pulse  is  quickened,  120-150,  but  does  not  main- 
tain its  ratio  with  the  accelerated  respiration,  which  reaches  fifty  or  even 
ninety  per  minute,  changing  in  character  to  the  pneumonia  type,  the 
pause  occurring  after  inspiration,  expiration  being  accompanied  by  a 
grunt  or  moan.  Dilatation  of  the  nostrils  and  recession  of  the  soft 
parts  of  the  chest  walls  accompany  inspiration.  The  expression  of  the 
face  is  that  of  preoccupation  or  even  anxiety.  The  child  may  insist 
upon  sitting  or  being  supported  in  the  upright  position  to  facilitate 
breathing. 

The  cough  may  be  dry  and  hacking,  or  whistling  in  character,  and 
is  followed  by  a  short  cry  indicative  of  pain.     More  or  less  cyanosis  is 

produced  pulmonary  lesions  which  were  usually  of  the  bronchopneumonic  typo. 
Lobar  lesions  developed  chiefly  in  animals  showing  greater  power  of  resistance. 
Animals  were  then  immunized  by  injecting  high  virulence  and  low  virulence  micro- 
cocci. In  the  animals  protected  by  the  high  virulence  micrococci  a  lobar  type  of 
lesion  was  obtained.  If  the  resistance  were  not  sufficient  to  prevent  the  production 
of  the  bacteria^mic  type  of  infection,  the  lesions  were  generally  of  the  bronchopneu- 
monic form.  Lobar  pneumonia  developing  in  a  resistant  and  immunized  animal 
was  comparable  to  lobar  pneumonia  developing  in  a  robust  individual. 


350  DISEASES    OF    THE    RESPIRATORY    TRACT 

present  or  is  easily  induced  by  coughing,  excitement,  or  nursing.  Thirst 
is  evident  but  the  child  may  refuse  the  breast  or  liquids  on  account  of 
the  dyspnoea.  There  are  coated  tongue,  anorexia,  frequently  distended 
abdomen,  green  stools  and,  occasionally,  early  vomiting. 

Percussion  in  the  first  two  days  of  the  attack  may  yield  nothing  ex- 
cept hyperresonance.  Auscultation  shows  a  variety  of  moist  rales  in- 
dicative of  bronchitis,  possibly  subcrepitation  and  exaggerated  respira- 
tory sounds.  Occasionally,  by  the  second  day,  a  circumscribed  area  may 
be  found  over  which  the  breath-sounds  are  indistinct,  and  light  percus- 
sion shows  dulness. 

All  the  symptoms  may  increase  in  intensity,  the  sthenic  pulse  may 
become  weak  and  irregular,  cyanosis  become  marked,  the  right  heart 
show  distention,  and  cerebral  symptoms,  with  rigidity  of  the  neck,  may 
develop.  Possibly  a  well-defined  area  of  consolidation  may  be  located  in 
a  posterior  or  lateral  portion  of  the  lung,  with  bronchial  breathing  and 
increased  vocal  resonance.  The  cough  is  restricted  and  the  sputum  which 
escapes  from  the  trachea  is  swallowed,  to  which  fact  is  attributed  the 
occasional  accompanying  gastric  disturbance.  The  attack  may  continue 
from  one  to  three  weeks  for  the  mild  cases,  with  a  gradual  improvement 
of  all  the  symptoms  as  the  temperature  declines  by  lysis.  In  a  small 
number  of  cases  a  true  crisis  occurs  like  that  of  fibrinous  pneumonia. 
Occasionally  there  are  exacerbations  as  other  portions  of  the  lungs  are 
involved  in  the  inflammation,  so  that  the  pneumonia  may  cover  a  period 
of  from  four  to  twelve  weeks. 

Weakly  children  and  marasmic  infants  at  times  develop  broncho- 
pneumonia which  may  run  a  fatal  course  in  from  two  to  six  days,  with 
normal  or  subnormal  temperature.  The  cough  may  be  slight  or  absent 
altogether,  rapid  respiration  and  cyanosis  being  the  principal  indica- 
tions of  pulmonary  lesion. 

In  infants  gastro-enteritis  not  infrequently  terminates  in  a  fatal 
bronchopneumonia  of  brief  duration,  in  which  the  symptoms  are  masked 
or  the  lung  invasion  may  be  marked  by  a  sudden  rise  of  temperature, 
with  cough  and  rapid  respiration.  In  measles  the  pneumonia  may 
accompany  the  exanthem  or  develop  after  the  disappearance  of  the  rash. 
This  type  is  apt  to  be  severe  on  account  of  the  weakened  resistance  due 
to  the  primary  disease.  It  frequently  runs  a  prolonged  course,  followed 
by  death  or  obstinate  sequela?. 

Complications. — The  commonest  complication  of  bronchopneumonia 
is  pleuritis,  which  is  often  followed  by  a  serous  or  purulent  effusion. 
Although  the  blood  in  bronchopneumonia  usually  shows  an  increase  in 
leucocytes,  a  marked  leucocytosis  developing  in  the  course  of  the  disease 
should  make  us  suspicious  of  pyothorax.  Examination  of  pus  from  the 
pleural  cavity  reveals  the  infective  agent  of  the  disease,  usually  the 
pneumococcus,  alone  or  accompanied  by  other  forms. 

Cardiac  complications  are  not  common,  although  pericarditis  is  occa- 
sionally seen.  It  is  rarely  diagnosed  from  the  pleuritic  effusion  with 
which  it  is  associated.    Purulent  meningitis  develops  in  a  small  number 


BRONCHOPNEUMONIA  351 

of  eases  and  should  not  be  confused  with  the  cerebral  symptoms  of  the 
stage  of  hyperpyrexia.  Stomatitis  of  various  forms  and  degrees  of 
intensity  is  common  in  protracted  bronchopneumonia. 

Gastro-enteritis,  although  frequently  the  primary  disease  of  broncho- 
pneumonia, especially  of  young  infants,  is  not  common  as  a  secondary 
complication. 

Sequela. — Among  the  sequelae  are  chronic  bronchopneumonia,  en- 
largement of  the  bronchial  glands,  bronchiectasis,  emphysema,  tubercu- 
losis, abscess  and  gangrene  of  the  lung.  The  last  named  are  rarely  seen 
except  in  pneumonia  due  to  the  aspiration  of  foreign  substances.  As 
all  of  these  conditions  are  separately  considered  elsewhere,  it  may  suffice 
to  state  that  although  bronchopneumonia  due  to  tuberculosis  is  common, 
pulmonary  tuberculosis  is  not  so  frequently  a  sequel  of  bronchopneumonia 
as  was  formerly  taught.  The  appearance  of  miliary  tuberculosis  in 
cachectic  children  may  possibly  have  been  hastened  by  the  debility  inci- 
dent to  the  pneumonia,  or  it  may  be  that  the  cough  and  congestion  may 
have  promoted  the  resolution  of  cheesy  pulmonary  nodules,  liberating 
tubercle  bacilli. 

Diagnosis. — In  the  absence  of  positive  signs  of  other  diseases,  bron- 
chopneumonia may  be  diagnosed  in  an  infant  by  persistent  fever, 
cough  and  rapid  respiration,  which  has  a  ratio  to  pulse-rate  of  1  to  2y2 
or  1  to  2.  From  uncomplicated  bronchitis,  bronchopneumonia  may 
be  diagnosed  in  the  first  two  or  three  days,  and  occasionally  throughout 
the  attack,  only  by  the  greater  intensity  of  the  symptoms.  Sometimes, 
however,  subcrepitant  rales  heard  at  the  base  of  the  lungs  indicate 
bronchopneumonia.  The  increased  resonance  on  percussion  also  suggests 
pneumonia.  The  continuance  of  the  temperature  beyond  three  or  four 
days,  with  dyspnoea  and  prostration,  are  not  common  to  bronchitis.  In 
cachectic  children  with  enlarged  superficial  lyniph-nodes,  the  diagnosis 
of  acute  catarrhal  pneumonia  from  tuberculosis  is  often  impossible.  In 
some  instances  the  diagnosis  may  be  determined  by  the  presence  of 
tubercle  bacilli  in  the  sputum.  From  fibrinous  pneumonia,  it  differs 
in  the  preceding  bronchitis,  age  of  the  patient,  occurrence  in  weakly 
children,  or  those  recovering  from  the  infectious  disorders,  more  gradual 
onset,  rarity  of  early  signs  of  consolidation,  atypical  course,  tedious 
resolution,  tendency  to  relapses,  and  defervescence  by  lysis. 

Prognosis. — The  mortality  of  bronchopneumonia  is  high.  The  con- 
ditions unfavorable  to  recovery  are  early  infancy,  malnutrition,  cachexia, 
bad  environment,  and  the  gravity  of  the  infection  to  which  the  pneu- 
monia is  secondary.  In  infants  of  the  first  year  the  mortality  may 
exceed  fifty  per  cent.  As  a  complication  in  whooping-cough,  diphtheria, 
measles,  and  scarlet  fever,  the  prognosis  is  grave  in  inverse  ratio  to  age. 
In  the  gastro-enteritis  of  infants,  bronchopneumonia  is  frequently  a 
fatal  complication.  In  all  the  acute  infectious  disorders  of  childhood, 
bronchopneumonia  should  be  closely  watched  for,  as  its  development 
adds  doubt  to  a  prognosis  otherwise  hopeful. 

Children  in  institutions  and  crowded  tenement  districts  show  little 


352  DISEASES    OF    THE    RESPIRATORY    TRACT 

resistance  to  this  disease  as  compared  with  those  in  good  sanitary  sur- 
roundings. 

Treat  mint. — The  evidences  of  the  contagions  character  of  secondary 
bronchopneumonia  demand  prophylactic  measures  in  epidemics  of 
measles,  pertussis,  diphtheria,  scarlet  fever,  or  influenza.  Efforts  at  dis- 
infection of  the  mouth,  nose,  and  pharynx  of  the  child  suffering  from 
an  acute  infectious  disorder,  by  the  use  of  antiseptic  sprays  and  gargles, 
should  never  be  neglected.  Poorly  nourished  or  rhachitic  children,  as 
well  as  those  convalescing  from  acute  disorders,  should  be  protected 
from  undue  exposure  to  cold  and  dampness  on  the  one  hand,  and  from 
confinement  in  poorly  ventilated  rooms  on  the  other.  Children  with 
whooping-cough  should  be  kept  in  the  open  air  when  possible.  The 
sputum  and  vomitus  of  pneumonic  patients  should  be  promptly  de- 
stroyed and  their  clothing  and  bedlinen  should  be  regularly  disinfected, 
while  the  patient  must  be  isolated  from  other  children.  In  no  other 
disease  is  good  nursing,  in  all  that  the  term  implies,  more  valuable  than 
in  bronchopneumonia.  Since  no  specific  medicine  is  known,  the  treat- 
ment must  conform  to  the  indications  of  the  individual  case. 

The  fatality  of  the  first  four  days,  during  the  stage  of  intense 
congestion,  may  be  lessened  by  early  derivative  and  revulsant  meas- 
ures, such  as  prompt  catharsis,  enteroclysis,  and  the  application  of 
rubefacients  to  the  chest  and  heat  to  the  extremities.  To  maintain 
hyperemia  of  the  surface,  mustard  paste  may  be  applied  to  the  chest  for 
a  few  minutes,  •  at  intervals  of  a  half  hour,  or  turpentine  and  lard 
(1  to  4),  with  thorough  massage  every  four  to  six  hours  for  the  same 
purpose.  The  tendency  of  turpentine  to  induce  strangury  must  be 
kept  in  mind  and  the  urine  watched.  The  hot  bath,  with  or  without 
mustard,  causes  determination  of  blood  to  the  surface,  relieves  conges- 
tion of  the  lungs,  and  is  efficient  in  the  developing  cyanosis.  The  feet 
should  be  kept  hot  by  means  of  a  hot-water  bottle,  and  the  head  cool  by 
frequent  bathing  with  tepid  water  and  alcohol  or,  in  severe  cases,  by  the 
ice-cap. 

Leeches  may  be  applied  to  rugged  infants  for  the  relief  of  con- 
gestion of  the  right  heart,  as  in  fibrinous  pneumonia.  Delicate  infants 
and  children  weakened  from  the  primary  disease  often  require  early 
stimulation  by  brandy,  strychnia,  digitalis,  or  nitroglycerin.  Belladonna 
or  its  alkaloid  not  only  aids  in  sustaining  the  heart  but  stimulates  res- 
piration and  helps  to  allay  the  troublesome  cough  which  is  depriving 
the  child  of  needed  rest.  Small  doses  of  bromides  are  useful  for  restless- 
ness. If  cerebral  symptoms  develop,  it  should  be  given  in  full  doses. 
Opium  is  rarely  indicated  in  bronchopneumonia,  and  many  popular 
expectorant  mixtures  may  well  be  omitted.  A  vigorous  child  may  be 
given  an  emetic  of  ipecac  to  expel  tenacious  mucus.  Inverting  the  child 
will  aid  the  extrusion  of  viscid  sputum  from  the  trachea  and  larynx, 
and  frequent  changing  of  the  position  will  lessen  the  hypostasis  in  de- 
pendent portions  of  the  lung.  Persistent  high  temperature  calls  for 
frequent  sponge  bathing  or  packs,  the  temperature  of  which,  if  reaction 


CHRONIC    INTERSTITIAL    PNEUMONIA  353 

be  good,  may  be  reduced  from  95°  to  80°  F.   (35°-26°  C.)  or  even  to 

70°  P.  (21°  C),  according  to  indications. 

The  dyspnoea  from  bronchial  secretion  and  congestion  calls  for  moist 
atmosphere.  The  croup  kettle  and  tent  often  afford  relief.  Turpentine, 
eucalyptol,  and  creosote  may  be  added  to  the  boiling  water.  Cases  have 
been  reported  of  phenic  acid  poisoning  in  infants  from  the  long-con- 
tinued inhalations  of  vapo-cresoline  in  a  closed  room.  The  evident  de- 
mand for  oxygen  should  keep  free  ventilation  uppermost  in  the  minds 
of  the  physician  and  nurse. 

From  the  nature  of  the  disease  and  the  character  of  its  victims,  the 
need  of  supporting  measures  in  bronchopneumonia  is  obvious,  hence  the 
greatest  care  should  be  given  to  feeding.  The  diet  must  be  liquid,  con- 
centrated, and  administered  frequently  in  small  amounts,  in  order  to 
secure  the  best  nutrition  and  avoid  the  serious  complications  of  indi- 
gestion and  overdistention  of  the  stomach  and  intestines. 

Convalescence,  so  frequently  tedious,  requires  the  judicious  oversight 
of  exercise  and  food,  and  the  use  of  tonics ;  as  iron,  quinia,  and  strych- 
nia. Protracted  convalescence  is  best  met  by  removal  to  a  climate  where 
the  patient  can  have  an  outdoor  life,  and  yet  be  free  from  extremes  of 
temperature  and  humidity. 

CHRONIC    INTERSTITIAL   PNEUMONIA — PERIBRONCHITIS;     PULMONARY    FIBRO- 
SIS;   FIBROID  PHTHISIS;     CIRRHOSIS  OR  INDURATION  OF  THE  LUNG. 

Under  the  above  terms  a  variety  of  conditions  is  indicated  which  may 
result  from  a  prolongation  or  from  frequent  recurrence  of  pneumonic 
attacks.  The  law  holds  good  here  that  prolonged  irritation  and  congestion 
of  organs  or  tissues  result  in  hyperplasia  of  connective  tissue.  In  the 
lungs  this  fibrosis  occurs  at  the  expense  of  the  functionating  structures, 
so  that  their  identity  is  lost.  The  tubes  may  become  strangulated  or 
distended  by  the  contraction  of  the  surrounding  fibrous  tissue.  Alveolar 
septa  and  bronchial  walls  are  thickened,  the  air-cells  are  crushed  together 
or  filled  with  organized  exudate,  the  pleuras  are  thickened,  agglutinated 
and  bound  to  the  lung  by  fibrous  bands  which  penetrate  its  walls.  As 
a  result  there  is  diminution  in  the  size  of  the  lung,  with  areas  of  in- 
creased density  in  one  part  and  compensatory  emphysema  in  another, 
and  sacculated  or  cylindrical  bronchiectasis  in  the  denser  portions.  Ex- 
tensive fibrosis  is  usually  confined  to  one  lung,  more  frequently  to  the 
base,  although  induration  occasionally  appears  primarily  in  the  apex. 

The  heart  may  become  displaced  by  contraction  of  the  lung,  and  its 
right  side  become  dilated  or  hypertrophied  from  obstruction  to  the  lesser 
circulation. 

Symptoms. — The  symptoms  and  signs  of  chronic  pneumonia  will  ob- 
viously vary  with  the  degree  and  duration  of  the  fibroid  changes.  The 
continuance  of  cough,  rapid  respiration  or  dyspnoea,  with  physical  signs 
of  delayed  resolution  after  the  subsidence  of  temperature  in  acute 
pneumonia  should,  in  the  absence  of  emphysema,  arouse  the  suspicion 
of  a  chronic  process.     This  is  especially  true  in  children  of  feeble  re- 

21 


354  DISEASES    OF    THE    RESPIRATORY    TRACT 

sistance  who  show  progressive  emaciation  and  prostration,  and  in  those 
who  have  suffered  from  repeated  attacks  of  pneumonia.  The  tempera- 
ture may  be  recurrent  at  intervals  of  weeks  or  months  upon  the  slightest 
exposure.  The  health  may  not  appear  much  affected  in  the  early  stages, 
although  the  child  usually  shows  deficiency  in  vigor,  is  short  of  breath 
upon  slight  exertion,  and,  if  old  enough,  expectorates,  sometimes  copiously 
in  the  morning,  foul-smelling  sputum.  Physical  examination  may  reveal 
consolidated  areas  of  dulness  and  absence  of  respiratory  sounds  in  some 
parts  of  the  lungs,  with  hyperresonance  and  amphoric  breathing  from 
dilated  tubes  and  emphysematous  lobules  in  others.  As  the  process 
advances,  the  respiratory  movements  of  the  affected  side  diminish  and 
there  may  be  retraction  and  later  recession  of  the  chest  wall,  which 
amounts  to  a  deformity,  with  later  curvature  of  the  spine,  prominence  of 
the  clavicle,  depression  of  the  shoulder,  and  clubbing  of  fingers  and  toes. 
Hectic  fever  may  develop  with  emaciation  and  general  debility.  Haemop- 
tysis is  occasionally  seen. 

Diagnosis. — Excluding  empyema,  which  should  have  been  demon- 
strated early  by  exploratory  puncture,  the  main  interest  centres  in  the 
diagnosis  of  chronic  pneumonia  from  pulmonary  tuberculosis.  In  many 
cases  this  is  extremely  difficult  as  the  cirrhotic  process  may  not  have 
become  sufficiently  extensive  to  obscure  the  sounds  of  the  accompanying 
bronchitis.  AVhen  hectic  temperature  is  an  accompaniment,  pulmonary 
fibrosis  may  closely  simulate  pulmonary  tuberculosis.  The  majority  of 
children,  however,  who  have  not  succumbed  to  intercurrent  disease  before 
this  stage,  are  old  enough  to  expectorate.  Repeated  sputum  examinations 
should  reveal  Koch's  bacilli  in  most  cases  of  tuberculosis. 

The  coexistence  of  a  tubercular  process  in  the  apex  with  general 
fibroid  phthisis  is  probably  not  a  rare  condition,  although  undiagnosed 
because  walled  off  by  the  adjacent  fibrosis. 

Prognosis. — Chronic  interstitial  pneumonia  is  essentially  a  progressive 
disease  and  when  well  established  a  cure  is  not  to  be  expected.  Much 
may  be  done,  however,  for  the  relief  of  symptoms  and  prolongation  of 
life.  In  the  earlier  stages  cures  are  possible.  The  condition  of  the 
lungs  is  such  as  to  favor  tubercular  invasion  or  the  development  of 
tuberculosis  from  caseous  degeneration  of  preexisting  tuberculous  lymph- 
nodes,  so  that  chronic  pneumonia  frequently  terminates  as  a  miliary 
tuberculosis. 

Treatment. — The  treatment  is  mainly  hygienic  and  supporting.  The 
most  nutritious  food  should  be  supplemented  by  cod-liver  oil  and  general 
tonics,  as  iron,  arsenic,  quinia,  and  strychnia,  while  iodine,  iodide  of 
potassium,  or  syrup  of  the  iodide  of  iron,  are  considered,  to  a  certain 
extent,  specific  in  promoting  absorption  of  exudates  and  the  arrest  of 
fibrosis.  Life  in  the  open  air,  with  but  moderate  exertion,  should  be 
followed  as  far  as  possible.  A  change  of  climate  may  be  necessary  to 
secure  the  proper  conditions  of  dry  atmosphere  and  uniform  tempera- 
ture. Inhalations  may  be  used  as  for  bronchiectasis  and  bronchitis 
(pages  329-333).    Breathing  exercises  and  light  gymnastics  may  do  much 


HYPOSTATIC    PNEUMONIA  355 

to  retain  respiratory  power  and  increase  oxygenation.     Stimulating  ex- 
pectorants, especially  of  the  balsamic  class,  may  be  useful. 

HYPOSTATIC   PNEUMONIA. 

Hypostatic  pneumonia  is  a  condition  which  develops  in  the  course  of 
debilitating  disease  as  a  result  of  enfeeblement  of  the  circulation  and 
prolonged  decubitus.  It  occurs  in  the  most  dependent  portions  of*  the 
lungs,  notably  on  the  posterior  surface  where,  yielding  to  the  persistent 
venous  stasis,  the  alveoli  become  filled  with  loosened  epithelium  and 
blood  elements  by  diapedesis  from  the  engorged  and  weakened  vessels 
in  their  walls.    It  is  usually  bilateral. 

The  condition  is  not,  strictly  speaking,  inflammatory  and  is  not  ac- 
companied by  a  rise  in  temperature.  It  is  usually  diagnosed  at  the 
autopsy  and  was  formerly  supposed  to  be  due  to  agonal  or  post-mortem 
changes.  Indications  of  pulmonary  hypostasis,  however,  are  present 
before  death  and  may  be  seen  in  the  respiratory  embarrassment  and 
sometimes  in  the  dulness  on  percussion  which  occupies  a  strip  parallel 
with  the  spine  on  both  sides  of  the  chest  posteriorly.  This  condition  adds 
gravity  to  the  disease  which  it  complicates,  as  typhoid  fever,  marasmus, 
and,  especially,  bronchopneumonia. 

The  treatment  of  hypostatic  pulmonary  congestion  is  mainly  prophy- 
lactic and  consists  in  frequent  changes  in  the  position  of  the  little 
patient,  especially  from  the  dorsal  decubitus;  while  stimulation  of  the 
heart  is  maintained  by  the  administration  of  digitalis,  alcohol,  strychnia, 
or  citrate  of  caffeine.    In  infants,  strong  black  coffee  may  be  useful. 

ABSCESS   OF    THE   LUNG   AND    PULMONARY  GANGRENE. 

Although  abscess  of  the  lung  rarely  occurs  except  as  a  complication 
or  sequel  of  other  acute  processes,  it  is  worthy  of  separate  consideration 
on  account  of  the  gravity  of  the  condition  and  the  difficulties  attending 
the  diagnosis. 

Later  reports  show  the  occurrence  of  pulmonary  gangrene  in  child- 
hood to  be  of  greater  frequency  than  was  formerly  supposed.  Abscesses 
of  the  lung  may  be  single  or  multiple,  and  may  vary  in  size  from  a 
small  pea  to  the  involvement  of  an  entire  lobe.  They  may  be  caused  by 
infectious  emboli  from  distant  suppurating  foci;  aspiration  of  foreign 
bodies  which,  becoming  impacted  in  the  smaller  bronchi,  excite  inflamma- 
tion ;  infected  perforating  wounds  of  the  lung,  and  by  extension  of  a 
pyothorax.  It  may  follow  any  of  the  acute  infectious  diseases,  but 
by  far  the  greatest  number  of  reported  cases  of  pulmonary  abscess 
have  occurred  as  sequels  to  croupous  or  bronchopneumonia.  Any  or  all 
of  the  pyogenic  as  well  as  saprophytic  microbes  may  participate  in  the 
process.  Abscesses  are  occasionally  drained  which  show  a  preponderance 
of  the  pneumococcus.  The  pus  of  the  abscess  may  burrow  through  into 
the  pleural  cavity  or  into  a  neighboring  bronchus.  In  the  latter  case 
pus  will  appear  in  the  sputum  if  the  child  be  old  enough  to  expectorate. 
The  fetor  of  the  breath  will  suggest  the  gangrenous  process.     Shreds 


356  DISEASES    OF    THE    RESPIRATORY    TRACT 

of  fibrous  tissue  may  be  found  in  the  sputum,  and  haemoptysis  from 
eroded  blood-vessels  may  occur.  The  fever  and  cough  are  frequently 
mistaken  for  that  of  an  extension  of  the  primary  disease.  Evidences  of 
infection  are  seen  in  the  great  prostration,  the  erratic  temperature  and 
the  leucocytosis,  all  out  of  proportion  to  the  cough  and  extent  of  lung 
lesion.  The  physical  signs  may  be  those  only  of  the  primary  broncho- 
pneumonia, or  may  be  those  of  a  pleuropneumonia  with  sacculated 
effusion. 

Diagnosis. — Pulmonary  abscess  is  very  frequently  mistaken  for  em- 
pyema, and  operations  have  been  made  which  reveal  only  adherent 
pleural  surfaces,  even  though  previous  aspiration  had  shown  pus.  Coarse 
pleuritic  friction  sounds  should  negative  the  supposition  of  pus  in  the 
pleural  cavity  even  though  there  be  dulness  on  percussion  and  diminu- 
tion or  absence  of  respiratory  sounds.  The  repeated  failure  to  find  pus 
by  aspiration,  after  demonstrating  its  presence  at  the  same  level  by  a 
previous  puncture,  is  quite  suggestive  of  a  lung  abscess  as  against  pyo- 
thorax.  From  putrid  bronchitis  with  bronchiectasis  the  diagnosis  is  to 
be  made  by  the  absence  of  elastic  fibrous  tissue  and  lung  elements  in  the 
sputum  in  these  diseases,  as  well  as  by  the  more  marked  evidences  of 
sepsis, — as  prostration  and  high  temperature  in  the  case  of  abscess. 
Pulmonary  tuberculosis  may  simulate  gangrene  of  the  lung  in  the  for- 
mation of  vomica?,  with  or  without  hemorrhages.  Differential  diagnosis 
can  only  be  made  by  the  demonstration  of  Koch's  bacillus. 

Prognosis. — The  prognosis  is  always  grave,  although  in  series  of  oper- 
ations for  the  relief  as  high  as  sixty-one  per  cent,  of  recoveries  have  been 
reported.  Too  frequently,  however,  the  diagnosis  of  pulmonary  abscess 
is  made  at  the  post-mortem. 

Treatment. — The  treatment  is  essentially  surgical,  the  result  depend- 
ing much  upon  the  early  diagnosis,  the  nearness  of  the  abscess  to  the 
chest  wall,  and  the  character  of  the  infecting  organism. 

ATELECTASIS — COLLAPSE   OF   THE  LUNG. 

Pulmonary  atelectasis  is  frequently  seen  in  infancy  and  childhood, 
and  may  be  congenital  or  acquired.  The  former  condition  has  already 
been  described  (page  171).  In  this  connection  it  is  sufficient  to  state 
that  some  degree  of  congenital  atelectasis  may  persist  for  varying  periods 
and  may  become  an  important  factor  in  a  bronchitis  or  bronchopneu- 
monia of  infancy. 

Acquired  atelectasis  is  due  to  collapse  of  air-vesicles  of  one  or  more 
lobules  or  even  of  an  entire  lobe,  and  most  frequently  occurs  in  infants 
or  children  of  feeble  muscular  development,  especially  the  poorly  nour- 
ished and  rhachitic.  Alveolar  collapse  may  be  due  to  any  one  of  three 
classes  of  causes,  or  to  all  operating  conjointly:  First,  occlusion  of  a 
bronchus  or  bronchiole  will  produce  collapse  of  the  alveoli  in  the  area 
of  distribution,  whether  the  obstruction  be  due  to  a  foreign  body,  a  viscid 
plug  of  mucus,  or  to  swelling  of  the  mucous  lining  of  the  tube.  Whether 
the  residual  air  is  forced  by  the  resiliency  of  the  acini  past  the  obstruc- 


ATELECTASIS  357 

tion  which  blocks  the  return  of  fresh  air,  or,  being  imprisoned  in  the 
vesicles  distal  to  the  plug,  is  absorbed  by  the  blood-vessels,  the  result  is 
the  same, — viz.,  a  collapse  of  the  vesicles  by  pressure  of  surrounding 
alveoli  which  develop  compensatory  emphysema.  Second,  collapse  of  a 
portion  of  the  lung  may  be  caused  by  pressure  from  adjacent  structures, 
as  from  a  pleuritic  or  pericardial  effusion,  mediastinal  tumors,  abdomi- 
nal distention,  rhachitic  or  spondylitic  deformity  of  the  chest  wall  or 
from  the  superincumbent  weight  of  the  infant's  body  in  prolonged,  un- 
changed decubitus.  Third,  disturbed  innervation,  as  paresis  of  the  pneu- 
mogastric  (after  diphtheria)  or  intracranial  compression  of  the  respira- 
tory centre  may  induce  lung  collapse.  Atelectasis  may  occur  as  a  serious 
complication  in  any  of  the  acute  or  chronic  pulmonapathies  and  is 
especially  frequent  in  whooping-cough  with  bronchitis.  Bronchopneu- 
monia rarely  develops,  it  is  claimed,  without  more  or  less  precedent 
atelectasis,  and,  in  turn,  no  doubt  causes  extension  or  multiplication  of 
areas  of  collapse. 

The  location  and  extent  of  the  atelectasis  depends  upon  that  of  the 
obstruction  or  compression  which  induces  it.  In  bronchial  catarrhs  the 
posterior  and  more  dependent  portions  of  the  lung,  especially  the  lower 
lobes,  are  the  favorite  sites.  These  are  usually  bilateral.  The  consoli- 
dations may  occur  in  many  circumscribed  areas,  in  size  from  a  pinhead 
to  a  walnut,  and  when  superficial  appear  post-mortem  as  depressions 
on  the  lung  surface.  This  tissue  is  darker  than  that  of  the  surrounding 
lung  and  does  not  crepitate  on  pressure.  If  recent,  the  alveoli  may  be 
inflated  by  moderate  force.  If  of  long  standing,  these  areas  are  con- 
densed, carnified,  and  sink  in  water. 

Symptoms. — The  symptoms  are  those  of  deficient  oxygenation  de- 
pending for  their  intensity  upon  the  extent  of  lung  area  involved.  This, 
in  the  absence  of  other  demonstrable  causes  of  dyspnoea  and  cyanosis, 
should  always  suggest  the  probability  of  lung  collapse. 

The  respiration  is  rapid  with  inspiratory  dyspnoea  and  recession  of 
the  chest  walls.  The  pulse  is  rapid  and  feeble  with  normal  or  subnormal 
temperature  unless  elevated  by  accompanying  infection.  The  extremities 
are  cold  and  an  intermittent  cyanosis  is  usually  seen.  Auscultation  and 
percussion  yield  equivocal  signs  because  of  the  bronchopneumonia  and 
emphysema  nearly  always  present.  Dulness  due  exclusively  to  atelec- 
tasis can  rarely  be  demonstrated. 

Atelectasis  may  develop  suddenly  in  the  course  of  an  acute  broncho- 
pneumonia in  which  the  physical  signs,  especially  if  the  atelectatic  areas 
be  diffuse,  may  be  ambiguous  or  indistinguishable  from  the  pre-existing 
disorder.  Percussion  dulness  may  be  rendered  resonant  from  adjoin- 
ing or  overlying  emphysema.  Resonance,  fremitus  and  auscultatory 
signs  of  consolidation  are  masked  from  the  same  reason.  In  large 
areas  of  collapse  dulness  on  percussion,  absence  of  respiratory  sounds, 
and  retraction  of  the  chest  wall  over  the  area  in  inspiration  may  be 
found. 

Diagnosis. — Collapse  may  be  suspected  in  any  bronchopulmonary  dis- 


358  DISEASES    OF    THE    RESPIRATORY    TRACT 

order  upon  the  sudden  development  of  dyspnoea,  cyanosis  and  of  rapid 
respiration  out  of  proportion  to  pulse  and  temperature. 

From  pleurisy  it  is  diagnosed  by  the  absence  of  friction  sounds, 
bulging  chest  wall  and  aegophony  heard  over  an  effusion.  From  pneu- 
monia it  is  distinguished  by  the  absence  of  fever,  by  the  character  of  the 
sputum  and  presence  of  chest  retraction. 

Prognosis. — The  prognosis  of  pulmonary  atelectasis  depends  upon  its 
duration  and  the  removability  of  the  cause.  The  longer  the  duration  the 
more  serious  the  import,  as,  after  long  compression,  changes  occur  in  the 
vesicle  walls  which  prevent  their  re-aeration.  Hypostatic  congestion 
adds  still  further  to  the  embarrassment  of  the  function  of  the  affected 
lung.  In  feeble  children  demonstrable  atelectasis  must  always  be  re- 
garded as  grave. 

Treatment. — As  acquired  atelectasis  is  always  secondary,  the  treat- 
ment should  be  directed  to  the  removal  of  the  primary  cause.  After 
withdrawal  of  a  pleuritic  effusion  and  recovery  from  the  bronchitis  or 
bronchopneumonia,  the  child  should  receive  careful  attention.  Cool 
bathing  and  outdoor  exercise  each  day  should  be  insisted  upon.  The 
diet  and  method  of  feeding  should  be  under  strict  supervision,  that  the 
general  nutrition  and  strength  be  improved.  Distention  of  stomach  or 
intestines  must  be  avoided.  Respiratory  exercises,  gradually  increased 
and  persisted  in,  will  do  much  to  develop  the  weakened  lungs.  In 
infants,  this  desideratum  must  be  secured  by  frequent  change  of  posi- 
tion, massage,  causing  crying  by  spanking,  sprinkling  with  cold  water, 
etc.     Tonics  are  indicated. 

For  relief  of  the  dyspnoea  occurring  suddenly  in  an  attack  of  broncho- 
pneumonia alternate  hot  and  cold  baths,  stimulating  liniments  to  the 
chest,  and  a  free  supply  of  oxygen  are  recommended.  Liquefying  the 
viscid  mucus  is  favored  by  having  the  air  of  the  room  moistened  by 
steam  from  water  containing  turpentine,  eucalyptol,  or  benzoin. 

PULMONARY   EMPHYSEMA. 

Emphysema  not  infrequently  accompanies  the  pulmonopathies  of  in- 
fancy and  childhood.  In  fact,  the  relatively  greater  amount  of  con- 
nective tissue  favors  the  development  of  interlobular  emphysema  in  early 
life.  Vesicular  emphysema  may  develop  under  conditions  which  cause 
increased  air-pressure  in  the  pulmonary  alveoli.  The  loss  of  resiliency 
in  the  walls  of  the  vesicles  which  allows  their  overdistention  is  appar- 
ently due  to  inflammatory  lesions  of  the  lung  tissue,  hence  emphysema  is 
more  developed  during  and  after  bronchitis,  pneumonia,  etc.  The 
groups  of  alveoli  which  yield  most  readily  to  dilatation  are  those  situated 
in  the  superficies  of  the  lung,  especially  at  the  apices  and  along  the 
free  borders,  also  those  adjacent  to  areas  of  collapsed  lobules,  as  in  com- 
pensatory emphysema.  Among  the  causes  of  this  stretching  of  the  air- 
vesicles  and  infunclibula  may  be  mentioned:  first,  prolonged  violent 
paroxysms  of  coughing,  followed  by  a  sudden  inrush  of  air,  as  in  per- 
tussis and  chronic  bronchitis;    second,  back-pressure  in  the  bronchioles 


PULMONARY    EMPHYSEMA  359 

from  obstruction  to  expiration,  as  in  stenosis  of  the  larynx  and  upper 
air-passages,  obstruction  in  the  tubes  due  to  secretions,  exudate,  or  con- 
gestion of  their  mucous  linings,  and  most  frequently  to  spasmodic 
asthma. 

The  interalveolar  septa  may  give  way  under  the  pressure,  so  that 
two  or  more  air-cells  may  appear  as  one  enormously  distended  or  the 
rupture  of  the  alveoli  may  allow  air  to  escape  into  the  interstitial 
areas,  causing  interlobular  pulmonary  emphysema.  In  this  form  the 
air  may  find  its  way  along  the  root  of  the  lung  into  the  mediastinal 
areolar  tissue  and  thence  into  the  cellular  tissue  of  the  body,  becoming 
a  general  subcutaneous  emphysema. 

In  either  form  of  pulmonary  emphysema  the  lungs  are  actually  en- 
larged and  contain  an  excess  of  residual  air. 

Symptoms. — There  is  shortness  of  breath  on  slight  exertion  or  con- 
tinued dyspnoea,  with  or  without  asthma.  The  anteroposterior  diameter 
of  the  chest  is  increased,  the  general  shape  being  that  of  full  inspiration. 
The  color  of  the  skin  is  cyanotic  from  easily  induced  venous  stasis.  The 
fingers,  in  long-standing  cases,  are  clubbed  and  the  right  heart  shows 
dilatation  with  or  without  hypertrophy  and  occasional  tricuspid  insuffi- 
ciency with  accentuation  of  the  second  pulmonic  sound.  Percussion  of 
the  chest  gives  increased  resonance,  with  diminished  areas  of  cardiac  and 
hepatic  dulness  from  extension  of  the  emphysematous  lung  borders. 
Auscultation  gives  a  prolonged  expiratory  murmur  of  low  pitch,  with 
the  rales  of  the  co-existing  bronchitis  or  asthma.  The  heart  sounds  are 
somewhat  obscured  by  overlying  lung  tissue  and  the  apex  beat  is  diffuse. 

Prognosis. — The  prognosis  of  acute  pulmonary  emphysema  in  child- 
hood is  usually  good,  unless  due  to  a  chronic  intractable  lesion. 

Treatment. — The  treatment  should  include  the  best  of  hygiene  and 
the  relief  of  all  underlying  causes  of  emphysema. 

General  subcutaneous  emphysema  may  be  due  to  traumatism  in  any 
portion  of  the  respiratory  tract,  which  allows  the  escape  of  air  into  the 
areolar  tissue.  It  may  follow  a  puncture  of  the  aspirating  needle.  Its 
principal  symptom  is  dyspnoea  and  its  sign  is  a  swelling  and  puffmess 
of  the  skin  which  does  not  pit,  but  yields  a  crackling  crepitus  on  pressure. 

Cases  occasionally  recover  under  judicious  treatment,  which  should 
include  restriction  of  respiration  and  compression  over  the  seat  of  punc- 
ture by  bandaging,  with  the  judicious  employment  of  sedatives. 

PLEURITIS — PLEURISY. 

Pleurisy  is  a  very  common  disease  of  childhood  and  is  seen  most 
frequently  in  the  first  five  years  of  life.  The  youngest  infants  are  not 
exempt,  as  autopsies  on  still-born  children  have  shown  pleural  adhesions 
resulting  from  inflammation  in  utero.  A  predisposing  cause  is  malnutri- 
tion and  lowered  vitality ;  hence  it  accompanies  or  follows  most  of  the  dis- 
orders and  infections  of  early  life.  It  is  most  frequently  secondary  to 
pneumonia.  It  rarely  occurs  as  a  primary  disease  in  infants,  although 
such  cases  have  been  reported  in  later  childhood.    There  is  much  reason, 


360  DISEASES    OF    THE    RESPIRATORY    TRACT 

however,  to  believe  that  even  these  are  due  to  a  mild  type  of  broncho- 
pneumonia during  which  the  pleuritis  develops  so  rapidly  as  to  obscure 
the  early  symptoms  of  the  primary  disease.  Probably  the  best  and  pos- 
sibly the  only  illustrations  of  a  primary  pleuritis  are  seen  following 
traumatism  or  as  an  expression  of  rheumatic  poison. 

Pleuropneumonia  is  the  term  applied  to  cases  where  the  onset  of  the 
pleural  inflammation  is  apparently  coincident  with  that  in  the  lung. 
Exposure  to  cold  is  recognized  as  a  determining  cause,  although  the 
exciting  cause  is  believed  to  be  a  microbic  infection  from  any  of  the 
pyogenic  bacteria.  During  infancy  and  childhood  the  infective  agent 
is  the  pneumococcus  in  two-thirds  of  the  cases.  This  corresponds  in 
frequency  with  that  agent  in  the  pneumonias  of  this  period.  In  fact,  it 
is  probable  that  pneumonia  rarely  occurs  without  more  or  less  involve- 
ment of  the  adjacent  pleura.  Pleurisy  may  be  secondary  to  any  of  the 
acute  exanthems  and  most  of  the  infectious  diseases  of  childhood,  as  well 
as  rheumatism,  nephritis,  enteritis,  and  suppurative  lesions  in  any  part 
of  the  body,  although  extension  from  the  lung  is  probably  nearly  always 
its  origin  in  young  infants. 

Pleurisy  occurs  more  frequently  in  boys.  Like  the  pneumonias  with 
which  it  is  usually  associated,  it  is  seen  most  commonly  during  the 
season  of  greatest  inclemency.  Tuberculous  pleurisy  is  infrequent  in 
early  childhood  as  compared  with  adult  life. 

In  pleurisy  the  inflammation  may  vary  widely  as  to  the  location  and 
extent  of  the  pleura  involved,  the  quantity  and  character  of  the  inflam- 
matory products,  as  well  as  in  the  degree  of  constitutional  intoxication. 
Upon  these  different  effects  is  based  the  classification  of  the  disease  into 
dry,  serofibrinous,  and  purulent  pleurisies.  It  may  be  unilateral  or 
bilateral,  fissural,  interlobular,  or  diaphragmatic. 

From  the  onset  the  affected  pleura  loses  its  glistening  appearance 
and  may  be  coated  with  an  exudate  of  fibrinoplastic  lymph  (entangling 
bacteria,  leucocytes,  or  pus  corpuscles),  which  forms  a  gray,  green,  or 
yellowish  coating,  varying  in  thickness  from  a  sheet  of  paper  to  two  or 
three  millimetres.  The  pleura  may  become  greatly  thickened,  sending 
processes  of  newly  organized  connective  tissue  from  the  visceral  layer 
into  the  interlobular  spaces  of  the  lung  to  a  considerable  depth.  The 
exudate  favors  the  neighborhood  of  the  interlobar  fissures  in  its  first 
appearance,  but  is  usually  more  extensive  on  the  parietal  pleura.  The 
rapid  organization  of  the  fibrinous  coagulable  lyrnph  in  the  exudate 
results  in  adhesions  between  the  opposing  pleura?.  In  extreme  cases  the 
entire  sac  may  be  obliterated  by  their  agglutination.  Usually,  however, 
the  exudate  is  restricted  to  limited  patches.  The  tug  of  respiratory 
movements  upon  the  plastic  material  stretches  the  adhesions  into  fibrin- 
ous bands  or  ribbons  of  varying  length  and  density.  Obviously  the  most 
intimate  adhesions  will  occur  at  points  least  disturbed  by  the  respiratory 
movements,  as  in  the  apices.  Newly  organized  fibrinous  tissues  may 
convert  the  pleural  sac  into  a  multilocular  structure.  There  is  always 
more  or  less  increase  in  the  serous  secretion  in  pleurisy,  but  the  relative 


PLEURITIS  361 

amount  of  serum,  fibrin,  and  pus  varies  in  different  eases.  The  quantity 
of  serum  may  vary  from  one  to  forty  ounces.  The  form  known  as  "  dry 
pleurisy"  rarely,  if  ever,  exists  in  infants  and  young  children  except  as 
a  form  of  pleuropneumonia.  When  the  quantity  of  fluid  is  great  the 
lung  is  compressed.  This,  if  long  continued,  may  result  in  loss  of 
resiliency  and  in  atelectatic  consolidation.  The  diaphragm  is  forced 
downward,  with  displacement  of  spleen  and  liver,  and  the  heart  is 
crowded  toward  the  unaffected  side.  This  displacement  is  most  marked 
in  left-sided  effusions  when  the  cardiac  impulse  may  be  forced  far  to  the 
right  of  the  sternum. 

Where  extensive  adhesions  exist,  in  the  absence  of  copious  effusion, 
the  lung  may  be  bound  down  by  its  own  thickened  pleura  and  hyper- 
plastic interlobular  connective  tissue,  so  that  it  never  fully  regains  its 
former  size  and  function.  In  this  case  the  thoracic  walls  of  the  affected 
side  show  a  corresponding  retraction  with  resulting  permanent  deform- 
ity of  the  chest  and  spine. 

Symptoms. — The  onset  of  pleuritis  is  usually  abrupt,  but  may  be 
insidious  and  unsuspected  until  announced  by  the  signs  of  accumulated 
fluid  in  the  chest.  Occurring  in  the  course  of  a  bronchopneumonia  or 
an  exanthem,  the  onset  may  be  marked  by  a  distinct  exacerbation  in 
temperature  with  pain  and  dyspnoea.  In  older  children  the  pain  may 
be  over  the  affected  side,  but  in  infants  it  is  usually  referred  to  the 
epigastric  or  umbilical  region.  Distinct  pain  may  be  wanting  or  may 
be  only  elicited  by  firm  pressure  over  the  abdomen  which  displaces  the 
viscera  upward.  The  pulse  follows  the  febrile  movement  and  may  be 
full  and  sthenic.  It  may  show  labored  irregularity  in  proportion  to 
the  obstruction  in  the  pulmonic  circulation.  If  the  effusion  be  large, 
especially  on  the  left  side,  with  extreme  cardiac  displacement,  the  heart 
becomes  twisted  upon  its  attachments  and  labors  under  great  disad- 
vantage. 

Short  restrained  cough  is  a  frequent  symptom  and  the  respiration  is 
commonly  restricted  on  account  of  the  pain.  In  young  infants,  evi- 
dences of  severe  pain  are  usually  wanting  and  the  friction  rubs  are 
rarely  heard.  This  is  explained  in  part  by  the  early  occurrence  of  the 
effusion.  With  a  large  effusion,  inspection  of  the  chest  may  show  uni- 
lateral bulging.  This  may  be  confirmed  by  comparative  measurements 
from  spine  to  midsternal  line.  Young  children  rarely  show  the  inter- 
costal bulging  seen  in  older  children.  Percussion  gives  flatness  with  a 
peculiar  sense  of  increased  resistance  to  the  finger.  The  heart-beat  may 
be  displaced  to  the  right  of  the  sternum  in  extensive  accumulations  on 
the  left  side,  or  to  the  axillary  line  when  the  pressure  develops  in  the 
right  pleural  cavity.  Displacement  of  the  liver  is  sometimes  demon- 
strable, continuous  dulness  extending  as  low  as  the  umbilicus.  Traube's 
space  (the  area  of  stomach  resonance)  may  be  obliterated  in  left-sided 
effusion.  The  line  of  dulness  varies  but  little  with  changes  of  position. 
Gentle  percussion  may  outline  limited  collections  in  the  lower  lateral 
portion  of  the  chest.    The  effusion,  though  free,  does  not  always  tend  to 


362 


DISEASES    OF    THE    RESPIRATORY    TRACT 


collect  in  the  lowest  part  of  the  pleural  cavity.  At  the  same  time  hyper- 
resonance  may  be  elicited  in  the  infraclavicular  region  of  the  affected 
side. 

In  the  so-called  dry  forms  of  pleuritis  and  occasionally  in  the  early 
stage  of  the  serofibrinous  type,  auscultation  over  the  affected  side  yields 
a  characteristic  friction  sound.  This  may  be  differentiated  from  the 
finer  crepitations  of  pneumonia,  which  it  resembles,  by  its  presence 
during  both  inspiration  and  expiration.  Vocal  fremitus  and  bronchoph- 
ony may  be  diminished  or  obliterated  and  replaced  by  asgophony  over 
a  large  collection.  The  vocal  and  respiratory  sounds  may  be  heard  with 
a  quality  of  remoteness  if  but  little  fluid  intervene  between  the  lung 
and  chest  wall.  Walled  off  collections  in  sacculated  pleurisy  yield  their 
physical  signs  in  different  areas  independent  of  gravitation.  In  pleu- 
risy, with  extensive  fibrinoplastic  exudate,  percussion  may  show  dulness 


Fig.  146. — Exploratory  aspiration  of  chest. 

over  the  affected  area  from  the  thickened  pleura?  through  which,  how- 
ever, the  voice  and  respiratory  sounds  are  transmitted  with  a  quality  of 
nearness. 

The  course  and  duration  of  pleurisy  in  infancy  and  childhood  are 
modified  by  those  of  the  disorder  with  which  it  is  associated.  The 
febrile  movement  may  subside  in  from  three  to  five  days.  The  serous 
fluid  gradually  disappears  by  resorption  so  that  in  two  or  three  weeks 
there  is  no  evidence  of  the  attack  save,  possibly,  a  thickening  of  the 
pleurse  and  occasional  circumscribed  cohesion  of  the  surfaces.  The 
effusion,  however,  may  not  be  absorbed  and  the  continuation  of  tempera- 
ture with  emaciation,  prostration,  profuse  sweating,  and  other  evidences 
of  sepsis,  may  suggest  the  presence  of  pus.  This  is  further  confirmed  if 
the  chest  wall  of  the  affected  side  become  cedematous  and  an  examination 
of  the  blood  shows  leucocytosis. 


PLEURITIS  363 

Diagnosis. — The  diagnosis  of  pus  may  be  positively  made  by  explora- 
tory aspiration  of  the  chest.  This  may  be  done  by  a  large  hypo- 
dermic needle  under  proper  aseptic  precautions,  after  careful  Location 
of  the  area  of  greatest  dulness  (Fig.  146  J.  If  thick  pus  be  present  it 
may  not  tiow  readily  through  a  small  needle,  and  as  the  sharp  needle 
may  wound  the  surface  of  the  lung  or  diaphragm  during  the  movements 
of  respiration  or  struggles  of  the  child,  a  small  trocar  may  best  serve 
the  purpose  of  puncture.  This  should  be  removed  immediately,  leaving 
the  canula  in  situ.  Deep  puncture  is  rarely  necessary, — two  centimetres 
being  sufficient  in  most  cases. 

Pleurisy  should  not  be  confused  with  hydrothorax,  which  is  of  non- 
inflammatory origin  and  which  is  occasionally  met  with  as  a  part  of  a 
general  oedema,  due  to  disease  of  the  heart,  liver,  or  kidneys,  or  to  a 
hydremia  of  general  wasting.  The  diagnosis  should  be  made  by  other 
evidences  of  organic  lesions  and  the  general  symptoms  of  the  primary 
disorder. 

Pleurisy  with  serous  effusion  is  diagnosed  from  other  pulmonary 
disorders  by  flatness  on  percussion,  with  absence  or  diminution  in  vocal 
fremitus,  lessened  severity  of  general  symptoms,  and  displacement  of 
the  heart-beat.    The  diagnosis  is  confirmed  by  the  aspirating  needle. 

Prognosis. — The  prognosis  in  simple  acute  pleurisy  depends  upon  the 
character  of  the  effusion.  If  this  be  serous  or  serofibrinous,  resorption 
usually  occurs,  unless  tuberculous.  In  infancy  the  large  majority  of 
cases  are  of  a  purulent  character,  or  a  primary  serous  effusion  becomes 
purulent  if  absorption  is  long  delayed.  In  rare  cases  a  moderate  amount 
of  pus  may  be  absorbed  from  the  pleural  cavity  without  apparent  detri- 
ment to  the  patient.  As  a  rule  empyema,  unless  relieved,  produces  gen- 
eral secondary  infection  with  fatal  termination.  The  pus  may  find  exit 
by  burrowing  through  the  chest  wall,  diaphragm,  or  into  a  bronchus. 
The  prognosis  of  empyema  depends  upon  its  early  recognition  and  treat- 
ment, the  character  of  the  pus,  and  the  age  of  the  patient.  If  diagnosed 
before  the  development  of  general  septicaemia  or  while  the  strength  of  the 
patient  is  little  reduced,  early  evacuation  of  the  pus  gives  promise  of 
speedy  recovery.  This  is  particularly  true  if  the  pneumoeoccus  be  the 
infecting  organism.  Hence  the  importance  of  microscopic  examination 
of  the  pus  obtained  by  exploratory  aspiration.  If  the  effusion  shows 
streptococci,  tubercle  bacilli,  or  mixed  pyogenic  forms,  the  prognosis 
is  grave,  although,  with  the  exception  of  tubercular  infection,  life  may 
be  saved  by  prompt,  thorough,  surgical  treatment. 

Sacculated  collections  in  the  pleural  cavity  and  pulmonary  abscesses 
are  usually  diagnosed  post-mortem.  Isolated  exudation  in  a  fissural  in- 
flammation and  a  diaphragmatic  pleurisy  present  many  difficulties  in 
differentiation  from  each  other  or  from  pulmonary  abscess  in  the  sub- 
stance of  the  lung.  The  aspiration  may  show  different  kinds  of  fluid 
from  different  punctures  closely  adjacent,  or  the  needle  may  find  pus 
at  one  aspiration  and  fail  to  find  it  with  repeated  later  efforts,  although 
introduced  at  the  same  point.    In  this  latter  event  a  deep-seated  abscess 


364  DISEASES    OF    THE    RESPIRATORY    TRACT 

may  be  suspected.  In  the  former,  separate  walled  off  collections  exist, 
representing  different  stages  of  pleuritic  inflammation. 

Treatment. — Acute  pleurisy,  if  seen  early,  should  be  treated  by  re- 
vulsants,  eliminants,  and,  if  necessary,  by  sedatives.  Free  catharsis 
by  an  initial  dose  of  calomel,  followed  by  a  saline,  with  rubefacient 
applications  or  dry  cups  to  the  surface  of  the  chest,  and  heat  to  the 
extremities,  tend  to  relieve  the  congestion  and  lessen  the  effusion.  Reap- 
plications  of  weak  mustard  paste,  sufficient  to  cause  marked  hypereemia, 
or  of  tincture  of  iodine  diluted  with  one  or  two  parts  of  alcohol,  may  be 
made.  Movements  of  the  chest  should  be  restricted  by  a  flannel  bandage. 
Strapping,  so  beneficial  in  adults,  is  objectionable  in  infancy  on  account 
of  the  extreme  delicacy  of  the  skin.  Excellent  results  are  obtained  in 
allaying  the  pain  and  shortening  the  duration  of  the  attack  by  the  use 
of  the  ice-bag. 

For  severe  pain,  restlessness,  and  dyspnoea,  codeine  by  the  mouth  or 
hypodermically  may  be  used  in  appropriate  doses.  Frequently  one  ad- 
ministration suffices  to  secure  relief  for  many  hours. 

Pleurisy,  preceded  or  accompanied  by  arthritic  or  other  manifesta- 
tions of  rheumatism,  may  call  for  the  exhibition  of  salicylates,  which  are 
claimed,  in  addition  to  bactericidal  properties,  to  limit  the  amount  of 
exudation  and  also  to  promote  absorption.  Tepid  sponging  affords 
comfort  and  promotes  elimination  by  the  skin.  Diaphoresis,  diuresis, 
extreme  catharsis,  and  dry  diet  are  of  doubtful  utility  in  limiting  the 
quantity  of  fluid  in  the  pleural  cavity  and  have  little  effect  in  causing 
absorption  of  the  exudate.  Care  of  the  stomach  and  bowels  is  necessary 
to  secure  nutrition  and  prevent  pressure  upon  the  diaphragm  from  over- 
distention. 

A  rapid,  weak,  and  irregular  pulse  may  require  a  cardiac  stimulant, 
as  digitalis,  strophanthus,  caffeine  citrate,  or  strychnia.  In  large  effu- 
sions with  marked  cardiac  displacement  and  dyspnoea  relief  may  be 
obtained  by  puncture  and  drainage  of  a  portion  of  the  fluid.  If  non- 
purulent, the  remainder  may  disappear  gradually  by  absorption.  If  the 
fluid  persist  beyond  two  or  three  weeks,  potassium  iodide,  one  to  ten 
grains  (0.065-0.65  Gm.)  according  to  age,  four  times  a  day,  may  hasten 
absorption.  Syrup  of  the  iodide  of  iron,  arsenic,  or  the  elixir  of  iron, 
quinia  and  strychnia,  may  be  given  as  hasmic  restoratives.  After  the 
acute  stage  the  child  should  be  allowed  to  sit  up  and  soon  to  move  about 
in  the  open  air.  Deep  breathing  should  be  practised  daily  to  expand  the 
lung.  Young  children  may  be  encouraged  to  blow  a  horn  or  soap- 
bubbles  for  the  same  purpose.  If  the  effusion  persist,  after  a  period 
of  several  weeks,  it  should  be  evacuated  to  prevent  permanent  injury 
to  the  lung  from  long  compression.  This  may  best  be  done  through  a 
hollow  needle  or  canula,  the  flow  of  fluid  being  promoted  and  the 
entrance  of  air  prevented  by  a  vacuum  aspirator,  such  as  Dieulafoy's. 
In  large  collections,  the  puncture  should  be  made  in  the  midaxillary 
line  in  the  fifth  or  sixth  interspace,  avoiding  the  lower  border  of  the 
rib.     The  child  should  be  in  a  half-reclining  position,  the  affeeted  side 


PLEUKITIS  365 

uppermost.  A  local  anaesthetic,  as  the  ethyl  chloride  spray,  may  be 
employed.  In  the  case  of  a  very  nervous  or  undisciplined  child  general 
anaesthesia  may  be  necessary.  The  fluid  should  be  withdrawn  very 
gradually.  Too  rapid  expansion  of  the  lung  induces  coughing  and  should 
be  restrained  by  compression  of  the  chest  by  the  hands  of  a  nurse  or 
by  a  firmly  drawn  bandage.  During  the  operation,  and  immediately 
after,  the  pulse  must  be  watched,  as  stimulants  may  be  necessary.  Com- 
plete evacuation  of  a  serous  effusion  is  rarely  necessary  or  advisable. 
After  withdrawal  of  the  needle,  sepsis  and  entrance  of  air  may  be 
guarded  against  by  the  application  of  a  collodion  dressing  or  a  bit  of 
plaster  over  the  puncture.  If  the  lung  be  tuberculous  it  is  well  not  to 
disturb  the  fluid  in  the  chest  unless  it  causes  threatening  symptoms,  as 
by  its  presence  compression  and  rest  of  the  affected  lung  is  secured,  with 
its  favorable  effect  in  limiting  the  extent  of  the  tubercular  process. 

The  diagnosis  of  empyema  calls  for  prompt  surgical  interference. 
As  a  rule  thorough  evacuation  of  the  pus  and  complete  drainage  are  the 
great  desiderata ;  hence  rib  resection  is  generally  favored  by  the  sur- 
geon. In  pneumococcic  pus,  however,  good  results  are  usually  obtained 
by  incision  and  the  quick  introduction  of  a  double  drainage  tube  between 
the  ribs.  In  addition  to  aseptic  precautions,  four  important  points  are 
to  be  observed  in  this  simple  operation :  First,  avoid  too  low  a  site  i:'or 
the  incision,  as  the  rising  diaphragm  may  press  upon  the  tube  and 
occlude  it ;  second,  prevent  the  entrance  of  air  by  constant  pressure 
upon  the  chest  wall  during  and  after  the  introduction  of  the  tube ;  third, 
do  not  wait  for  the  pus  to  stop  flowing  before  applying  the  dressing; 
and  fourth,  retain  an  abundant  absorbent  dressing  by  a  firmly  applied 
bandage.  Irrigation  is  rarely  necessary,  as  the  gradual  expansion  of  the 
lung  encourages  free  drainage  into  the  absorbent  dressing.  The  tube 
should  be  shortened  at  each  dressing  as  the  depth  of  the  cavity  dimin- 
ishes. One-half  of  the  tube  should  be  fenestrated,  the  other  half  entire, 
and  held  together  by  a  safety-pin  passed  through  their  walls  to  prevent 
them  from  dropping  into  the  pleural  cavity. 

Resection  of  a  rib  should  be  referred  to  the  surgeon. 


CHAPTER   X 

DISEASES   OF   THE   KIDNEYS,  BLADDER,  AND    GENITAL 

ORGANS 

ANURIA  AND  OLIGURIA 

Total  suppression  of  the  urine  in  the  new-born  may  be  due  to  mal- 
formation of  some  portion  of  the  urinary  tract,  as  imperforate  urethra 
or  ureters,  occlusion  of  either  by  calculi,  mucous  plugs,  blood-clots,  or 
accumulations  of  uric-acid  crystals.  Occasionally,  from  having  emptied 
the  bladder  during  birth,  the  infant  will  pass  no  urine  for  from  twelve 
to  twenty-four  hours.  This  fact,  and  the  rapid  loss  of  fluids  from 
bowels  and  by  evaporation  from  the  surface,  together  with  non-ingestion 
during  the  first  two  days,  might  well  explain  the  scanty  secretion.  The 
frequent  appearance  of  large  quantities  of  uric  acid  (brick-dust)  after 
temporary  suspension,  and  the  presence  of  uric-acid  infarcts  in  infants 
dying  of  anuria,  are  sufficient  explanation  for  a  common  obstruction  in 
very  young  infants. 

Scant  urine,  or  total  suppression  in  older  babies  and  children,  may 
be  due  to  any  cause  which  operates  by  diverting  the  fluids  to  other 
channels,  as  colliquative  diarrhoea,  vomiting,  and  sweating.  Obviously, 
high  temperature  and  hemorrhages  diminish  the  amount  of  fluid  to  be 
excreted.  In  older  children  particularly,  nervous  influences,  as  hysteria, 
affect  the  secretion  of  urine  to  a  remarkable  degree.  Irritation  of  the 
urinary  tract  by  certain  substances  may  cause  a  vesical  strangury  or 
complete  or  partial  suppression  from  acute  renal  congestion.  Turpen- 
tine, cantharides,  salicylates,  the  carbolic  acid  group,  ether  and  chloro- 
form, act  in  this  way,  whether  taken  internally,  by  inhalation,  or  by 
application  to  the  surface,  and  are  not  infrequent  causes  of  oliguria  or 
even  anuria.  Passive  congestion  from  thrombosis  of  the  inferior  vena 
cava,  or  renal  vein,  has  been  reported. 

Differential  Diagnosis. — Anuria  should  be  differentiated  from  reten- 
tion. The  distended  bladder  will  appear  as  an  abdominal  tumor  above 
the  pubis,  which  disappears  upon  catheterization.  The  retention  may 
be  due  to  obstruction  by  calculus,  or  partial  vesical  paresis  from  over- 
distention.  It  may  be  a  symptom  of  grave  neurosis,  as  from  transverse 
myelitis  or  other  affections  of  the  spinal  cord. 

Prognosis. — The  length  of  time  a  child  may  live  with  complete  anuria 
varies  from  three  to  fourteen  days.  The  lateness  of  the  development  of 
uraemic  symptoms  in  infants  is  an  interesting  clinical  fact. 

Treatment. — Anuria  should  be  treated  with  due  reference  to  the 
cause.  Congenital  malformations  and  calculus  call  for  prompt  surgical 
366 


ILKMATUKIA  367 

interference.  Water  is  the  best  diuretic,  especially  for  the  new-born. 
In  older  children  spiritus  aetheris  nitrosi,  potassium  acetate  or  citrate, 
may  be  given  every  hour  or  two.  Hot  fomentations  over  the  kidneys  or 
hot  baths  are  useful.  Enteroclysis  of  hot  normal  salt  solution  is,  perhaps, 
the  most  efficient  procedure. 

HEMATURIA. 

Blood  may  be  present  in  the  urine,  giving  it  a  dark  red  color,  a  smoky 
amber  hue,  or  may  only  be  discoverable  by  detection  of  corpuscles,  by 
chemical  test,  or  by  the  microscope.  If  the  urine  be  streaked  with  blood 
its  probable  source  is  the  urethra  or  bladder.  If  from  the  ureters,  pelvis 
of  kidney,  or  renal  tubules,  it  is  uniformly  disseminated  throughout  the 
urine,  and  will  form  tube  casts  or  the  larger  ureteral  moulds.  The 
passage  of  the  urine  into  two  glasses  will  occasionally  give  a  hint  as  to  the 
source  of  the  blood  in  the  difference  between  that  seen  at  the  beginning 
and  at  the  close  of  micturition. 

Irritation ;  trauma  from  falls,  blows,  catheterization  ;  calculi ;  acute 
nephritis;  active  or  passive  hyperaemia  of  the  kidneys  or  of  the  entire 
urinary  tract,  are  the  principal  causes.  To  these  should  be  added  such 
blood  dyscrasiae  as  haemophilia,  scorbutus,  purpura,  and  syphilis;  also 
neoplasms  of  the  kidney  or  bladder,  and  besides  malaria,  the  use  of 
quinine,  chlorate  of  potassium,  etc. 

Eecurrent  haeniaturia  may  require  differentiation  between  calculus 
or  uric  acid  crystals  and  carcinoma  as  to  the  cause.  Stone  should  pro- 
duce its  vesical  and  tubular  symptoms.  (See  Calculus.)  The  rather 
profuse  hemorrhage  from  carcinoma  rarely  occurs  until  far  enough  ad- 
vanced to  be  located  by  palpation.  The  presence  of  renal  sand  in  the 
urine  when  first  voided  and  still  warm  is  very  suggestive  as  a  cause. 

The  prognosis  and  treatment  are  entirely  dependent  upon  the  cause. 
The  general  indications  are  rest  and  protection  from  cold.  If  severe  or 
continued,  such  haemostatics  as  ergot,  gallic  acid,  and  suprarenal  extract 
may  be  tried. 

H/EMOGLOBINURIA. 

The  blood  pigment  may  appear  in  the  urine,  as  proved  by  Heller's 
test  or  spectrum  analysis,  accompanied  by  few  or  no  red  corpuscles. 
Albumin  is  always  present,  and  the  urine  may  be  red  or  almost  black 
from  the  blood  pigment  it  contains.  The  nature  of  the  haemolysis  which 
allows  the  escape  of  the  haemoglobin  from  the  cells  is  still  in  doubt.  Most 
of  the  exciting  causes  are  those  common  to  haematuria. 

A  paroxysmal  haemoglobinuria  from  unknown  etiology  occurs  with 
chill  followed  by  fever,  the  temperature  rising  from  101°  to  104°  F. 
(38.5°-40°  C).  The  urine  clears  up  after  the  subsidence  of  the  fever, 
with  the  exception  of  a  transient  albuminuria.  Obviously  the  treatment 
depends  upon  the  cause.* 

*  For  epidemic  haemoglobinuria  in  the  new-born,  see  Winckel's  Disease. 


368  DISEASES    OF    GEXITO-LTJXARY    TRACT 


INTERMITTENT    ALBUMINURIA ORTHOSTATIC,    POSTURAL,    CYCLIC,    FUNC- 
TIONAL,   PHYSIOLOGICAL   ALBUMINURIA. 

The  causes  of  albuminuria  constitute  a  subject  the  discussion  of  which 
has  brought  out  such  a  variety  of  opinions  that  a  detailed  consideration 
here  is  obviously  impracticable.  Is  the  term  physiologic  albuminuria  a 
misnomer  ?  Those  who  hold  that  albumin  may  not  be  present  in  normal 
urine  are  referred  to  the  albuminuria  of  the  newly  born,  which  appears 
in  over  fifty  per  cent,  of  infants.  On  the  other  hand,  those  who  claim 
that  cyclic  albuminuria  may  be  devoid  of  pathologic  significance  are 
referred  to  the  many  instances  in  which  unquestionable  nephritis  fol- 
lowed. When  the  great  variety  of  pathologic  conditions  that  may  cause 
or  at  least  precede  the  appearance  of  albumin  in  the  urine  is  consid- 
ered, the  inclination  is  strong  towards  the  conclusion  that  its  presence 
is  never  without  some  pathologic  significance,  and  that  the  diagnosis  of 
physiologic  albuminuria  is  but  another  expression  for  undetermined 
causation.  Without  appreciable  kidney  lesions  or  any  other  evidence  of 
impaired  health,  albumin  in  slight  amounts  may  appear  in  the  urine, 
either  continuously  or  periodically  (cyclic),  for  months  or  even  years. 
It  may  be  absent  from  the  urine  secreted  while  in  a  horizontal  position 
(first  morning  urine),  only  to  reappear  in  that  voided  sometime  after 
rising  or  during  the  day  (postural  or  orthostatic  albuminuria).  Albu- 
minuria is  occasionally  induced  by  the  overingestion  of  proteid  food 
(dietetic  albuminuria),  and  is  now  known  to  be  a  common  accompani- 
ment of  gastro-enteric  disorders  of  infancy.  An  analysis  of  all  the 
evidence  in  many  cases  of  albuminuria  without  demonstrable  kidney 
lesion  yields  many  facts  too  significant  of  albumin  production  to  be 
disregarded.  Thus  albuminuria  of  the  new-born  most  frequently  fol- 
lows dystocia.  Both  cyclic  and  continuous  albuminuria  usually  are 
observed  in  children  who  show  some  deviation  from  perfect  health, — as 
anaemia,  indigestion,  headache,  vertigo,  tendency  to  nervous  irritability, 
syncope,  and  malnutrition.  Transient  albuminuria  may  follow  cold 
baths,  shock,  fright,  unaccustomed  muscular  exercise,  and  undue  fatigue, 
not  to  mention  the  long  list  of  intoxications  and  infections  of  all  grades 
of  severity.  In  addition  to  this  we  may  have  intermittent  albuminuria, 
even  in  demonstrable  nephritis. 

In  all  the  varieties  of  haemic,  cardiovascular,  angioneurotic,  and 
trophic  conditions,  there  resides  and  ultimately  may  be  demonstrated  a 
cause  for  every  form  of  albuminuria. 

The  significance  of  albuminuria  depends  entirely  upon  associated 
conditions,  such  as  the  presence  or  absence  in  the  urine  of  blood,  pus, 
casts,  excessive  number  of  epithelial  cells,  or  mucus,  and  the  existence 
of  cardiac  hypertrophy,  high-tension  pulse,  fever,  etc. 

Too  commonly  neglected  is  differentiation  of  serum-albumin  and 
serum-globulin  from  the  other  proteids  of  slight,  or  as  yet  unknown, 
pathologic  importance,  such  as  nucleo-proteids,  albuminoses,  and  fibrin. 
The  presence  of  globulin,  a  usual  accompaniment  of  albuminuria,  is  only 


DISPLACEMENT    OF    THE    KIDNEY  369 

significant  when  its  quantity  equals  or  exceeds  that  of  serum  albumin, 
as  in  amyloid  degenerations.  Nucleo-proteid  alone  is  not  indicative  of 
renal  lesion,  but  may  be  due  to  epithelial  desquamation  in  any  portion 
of  the  urinary  tract.  Of  special  interest  in  differentiation  is  extrarenal 
albuminuria  or  urine  contamination  with  albumin  from  mucus,  blood, 
or  pus,  after  its  exit  from  renal  tubules. 

The  appearance  of  albumin  in  the  urine  is  of  more  frequent  occur- 
rence in  infancy  and  childhood  than  in  adult  life,  for  the  reasons  that 
the  conditions  conducive  thereto  are  more  common, — as  the  greater 
metabolism,  the  activity  of  the  glandular  system,  the  prevalence  of  acute 
infectious  diseases,  the  frequent  recurrence  of  febrile  disturbances,  and 
a  greater  tendency  to  uric  acid  formation.  In  this  connection  the  re- 
markable increase  of  metabolic  and  circulatory  activity  of  pubescence  is 
significant.  The  amount  of  albumin  is  usually  small, — from  a  mere 
trace  to  one-eighth  of  one  per  cent. 

Although  evidence  of  the  albuminuria  of  functional  disturbance  is 
increasing,  the  careful  physician  will  not  jump  at  the  conclusion  from 
the  co-existence  of  some  possible  functional  cause,  but  will  regard  every 
case  with  a  proper  degree  of  suspicion  of  beginning  organic  changes  in 
the  kidney,  and  keep  the  case  under  close  observation. 

KIDNEYS — MALFORMATIONS   AND    CONGENITAL    ANOMALIES. 

Probably  no  other  organ  exhibits  a  greater  frequency  or  variety  of 
congenital  anomalies  than  does  the  kidney.  There  may  be  entire  absence 
of  one  or  both,  rudimentary  formation,  fusion,  multiple  kidneys,  atrophy, 
movable,  cystic  degeneration,  double  pelvis,  hydronephrosis,  and  super- 
numerary ureters.  Entire  absence  of  both  kidneys  has  been  reported, — 
a  condition  which  renders  continued  extrauterine  existence  impossible. 
In  these  subjects  other  congenital  defects  are  usually  present. 

In  the  absence  of  one  kidney,  the  corresponding  ureter  is  wanting. 
Where  this  tube  is  present,  a  mass  appears  at  the  upper  end  repre- 
senting a  rudimentary  or  extremely  atrophied  kidney,  possibly  with 
renal  artery  and  vein  (Fig.  147).  Intrauterine  inflammation  is  prob- 
ably responsible  for  this  arrest  of  growth  or  retrograde  change.  Under 
these  circumstances  the  opposite  organ  is  always  enlarged  from  the 
necessity  of  increased  function.  The  deficiency  is  rarely  diagnosed 
during  life.  This  condition  is  of  special  interest  in  view  of  subsequent 
risk  from  the  development  of  renal  insufficiency  during  the  infectious 
diseases  of  childhood. 

The  kidneys  may  be  fused  at  their  upper,  middle,  or  lower  portions, 
commonly  the  latter,  forming  the  "horseshoe"  kidney,  which  usually  is 
supplied  with  two  pelves  and  ureters.  This  anomaly,  with  the  pre- 
ceding, is  of  surgical  interest  when  conditions  requiring  nephrectomy 
arise. 

Double  ureters  arising  from  separate  pelves  in  the  same  kidney  are 
occasionally  seen  and  may  enter  the  bladder  in  a  common  or  separate 
opening.     The  latter  is  of  interest  in  cystoscopic  work.     In  this  connec- 

24 


370 


DISEASES    OF    GENITO-URINARY    TRACT 


tion  the  possibility  of  anomalous  position  of  the  ureteral  orifice  in  the 
vesicle  wall  should  be  borne  in  mind. 

Displacement  of  the  kidney,  congenital  or  acquired,  is  not  rare, 
and  occurs  most  frequently  in  girls.  The  kidney  may  be  movable  or 
fixed,  displacement  varying  widely  in  degree  from  mere  palpability  even 
to  the  pelvis.  It  has  even  been  found  in  the  umbilical  cord  at  birth. 
This  possibility  conveys  a  caution,  as  it  has  been  injured  from  want  of 
recognition.     Occasionally  this   organ  is  fixed  in  malposition,   in   the 


Fig.  147.— Rudimentary  kidney,  aorta,  renal  vein,  and  artery.    Right  kidney  enlarged,  showing  acute 
inflammation  engrafted  upon  a  diffuse  nephritis.    Boy,  4  years  old. 


pelvis,  below  or  at  the  sacral  promontory.  In  this  locality  the  "  horse- 
shoe" kidney  is  usually  found.  Exploration  of  the  rectum  will  some- 
times reveal  the  dislocation. 

Symptoms  attributable  to  nephroptosis  are  pain  and  discomfort  in 
the  epigastric  region  independent  of  digestive  disturbance,  and  dragging 
in  the  loin,  relieved  by  recumbency  and  abdominal  support.  The  coated 
tongue  and  jaundice  have  been  explained  by  the  dragging  on  the  duode- 
num through  the  mesonephron.    Constipation  is  attributable  to  the  same 


DIKI'LACHMKXT    OF    THE    KIDXEY  371 

influence  on  the  colon.  Scant  urine  may  be  the  result  of  transient  hydro- 
nephrosis from  twisting  of  the  ureter  in  movable  displacements.  Renal 
mobility,  aside  from  traumatism,  may  result  from  two  causes,  the  rapid 
absorption  of  the  fat  which  assisted  in  retention  of  this  organ  in  its 
normal  position,  and  the  relaxation  of  extreme  debility,  congenital  or 
otherwise,  of  which  the  displacement  of  the  kidney  is  but  a  feature  of 
the  general  splanchnoptosis. 

In  the  treatment,  before  the  consideration  of  surgical  interference, 
efforts  should  be  directed  to  the  general  condition  and  improvement  of 
the  muscular  tone,  particularly  of  the  abdominal  wall.  Temporary  or 
even  permanent  relief  may  be  secured  by  an  abdominal  bandage. 


»•*,   23 


~>L 


Fig.  148.— Double  cystic  tumor  of  kidney.     (Rush  Medical  Museum.) 

Congenital  cystic  degeneration  of  the  kidney  is  presumably  due  to 
developmental  arrest  or  perversion  in  the  embryonic  tubules,  with  the 
formation  of  terminal  pouches.  These  subsequently  fill  with  fluid  and 
may  attain  enormous  dimensions,  rendering  delivery  difficult  or  impos- 
sible. One  kidney  alone  is  rarely  affected.  These  cysts,  although  usually 
multiple  at  birth,  develop  rapidly  with  a  tendency  to  coalescence,  and 
obliteration  of  all  normal  histological  structures  (Fig.  148).  When  dis- 
covered, they  appear  as  abdominal  tumors,  with  evidences  of  renal 
insufficiency.  If  both  kidneys  are  involved,  differentiation  from  hydro- 
nephrosis and  malignant  tumors  may  be  assumed  from  the  bilateral 
character.  Most  frequently  the  infant  does  not  long  survive  birth, 
although  occasionally  these  tumors  develop  slowly  until  adult  life. 


372  DISEASES    OF    GEXITO-URINARY    TRACT 

The  true  nature  is  usually  revealed  at  the  post-mortem.  No  curative 
measures  are  of  any  known  value. 

ACUTE   NEPHRITIS. 

Renal  morbidity  is  rarely,  if  ever,  confined  to  one  variety  of  histo- 
logic elements,  so  that  the  terms  glomerulo,  tubular,  and  interstitial,  as 
applied  to  acute  nephritis,  express  only  a  partial  differentiation  between 
the  coincident  pathologic  processes  and  conditions  of  the  disease  called 
nephritis.  Not  only  do  different  renal  elements  suffer  simultaneously,  to 
a  different  extent,  but  consecutively  the  pathologic  picture  changes  with 
the  advancement  of  the  morbid  processes. 

In  view  of  these  facts,  the  term  acute  nephritis  is  deemed  sufficiently 
comprehensive  to  express  a  disturbance  of  renal  function  which  is  very 
common  in  infancy  and  childhood.  No  separate  consideration  is  given 
to  acute  renal  congestion  for  the  reason  that  it  may  safely  be  regarded 
as  the  initial  stage  of  acute  nephritis  without  jeopardizing  either  the 
etiology  or  therapy.  A  primary  form  of  acute  nephritis,  especially 
among  very  young  infants,  is  reported  by  some  observers.  The  diagnosis 
can  be  made  only  in  the  absence  of  any  known  cause. 

Acute  nephritis  is  usually  due  to  the  presence  of  toxins  either  of  ectog- 
enous  or  endogenous  origin.  Its  relation  to  acute  infection  is  accepted 
as  proof  of  their  etiologic  importance.  There  is  ample  evidence  that  it 
may  be  due  to  syphilis.  Increasing  evidence  shows  its  relation  to  gastro- 
intestinal disorders,  especially  of  young  infants.  Many  chemical  and 
medicinal  agents  are  known  to  act  as  exciting  causes,  as  are  also  extensive 
burns  of  the  skin.  The  question  as  to  the  influence  of  cold  and  damp 
in  the  production  of  renal  incompetency  in  children  has  been  much  dis- 
cussed. The  mass  of  clinical  evidence,  however,  points  to  such  exposure 
as  a  frequent  cause,  at  least  in  the  precipitation  of  an  attack  of  acute 
nephritis. 

The  causative  relation  of  uricacidosis  has  received  confirmatory  evi- 
dence by  recent  observations  upon  young  infants  in  the  frequent  find- 
ings of  these  infarcts  in  those  dying  from  acute  nephritis. 

The  symptoms  of  acute  nephritis  may  be  quite  irregular  in  the  order 
of  their  appearance.  A  mistaken  notion  that  certain  classical  symptoms 
are  always  present  is  extremely  unfortunate,  because  many  cases  are,  no 
doubt,  overlooked.  The  symptoms,  too,  may  be  masked  by  those  of  the 
preceding  or  accompanying  disease,  of  which  the  nephritis  is  a  compli- 
cation or  sequel.  The  most  important  and  almost  constant  indication  of 
acute  nephritis  is  the  condition  of  the  urine,  which  should  be  systemat- 
ically examined  in  all  diseases  and  conditions  which  nephritis  may 
follow. 

The  urine  at  first  is  usually  lessened  in  quantity,  although  voided  fre- 
quently, or  there  may  be  complete  anuria.  The  specific  gravity  is  usually 
high.  The  appearance  is  turbid,  smoky,  or  even  dark  red  from  the  con- 
tained blood-cells.  On  standing  it  deposits  a  heavy  sediment.  Micro- 
scopic examination  shows  crystals  of  uric  acid  and  oxalate  of  calcium, 


ACUTE    NEPHRITIS  373 

renal  epithelium,  red  blood-cells,  also  hyaline,  epithelial,  and  blood-casts. 
Albumin  is  nearly  always  present,  from  one-fourth  to  one  per  cent.,  or 
the  urine  may  even  solidify  on  boiling.  Occasionally,  however,  the  spe- 
cific gravity  may  be  low  on  account  of  the  diminished  excretion  of  solids. 
The  percentage  of  urea  may  be  higher  than  normal,  although  the  total 
quantity  excreted  is  always  diminished. 

In  favorable  cases  the  quantity  of  urine  may  gradually  increase 
even  from  total  anuria,  with  more  or  less  rapid  diminution  in  the 
albumin,  blood,  and  casts,  with  increase  in  the  amount  of  urea,  the 
kidneys  resuming  their  normal  function  within  a  week.  Many  regard 
this  early  recovery  as  evidence  of  acute  hyperemia  rather  than  acute 
nephritis,  although  the  diagnosis  as  such  is  impossible  prior  to  its  early 
termination. 

The  return  of  the  kidneys  to  their  normal  function  may  be  more 
gradual,  so  that  weeks  elapse  before  the  urine  is  entirely  free  from  evi- 
dences of  renal  insufficiency.  Even  then  the  tendency  to  reappearance 
of  albumin  and  casts  from  slight  or  unapparent  causes  is  the  rule. 
Hence  the  importance  of  systematic  urinalyses  long  after  apparent  re- 
covery. Chronic  forms  of  renal  disease  almost  always  have  their  origin 
in  acute  attacks.  Unfortunately,  the  urinary  findings  proceed  from  bad 
to  worse,  diminished  quantity  and  increased  pathological  constituents 
rendering  prognosis  extremely  grave. 

There  is  usually  moderate  fever  at  the  beginning  of  the  attack,  occa- 
sionally following  a  chill,  although  the  temperature  may  be  normal  and 
in  rare  instances  subnormal  throughout.  The  rise  in  temperature  is 
frequently  mistaken  for  a  continuation  of  the  primary  disease,  and  in 
the  absence  of  other  symptoms,  without  examination  of  the  urine,  the 
diagnosis  will  be  overlooked.  Vomiting  is  occasionally  an  early  and 
frequently  a  late  and  unfavorable  symptom,  presaging  uraemia.  So,  also, 
headache  in  older  children,  dimness  of  vision  from  hemorrhagic  retinitis, 
restlessness,  or  apathy,  may  be  the  precursor  of  urasmie  coma  or  convul- 
sions. CEdema,  next  to  the  urinary  findings,  is  the  most  common  accom- 
paniment of  acute  nephritis ;  indeed,  this  symptom  has  long  been  re- 
garded as  pathognomonic  and  is  occasionally  the  first  and  only  (always 
excepting  the  urine)  indication  of  renal  involvement.  The  eyelids  ap- 
pear puffy.  There  is  slight  pitting  on  pressure  over  the  sternum.  The 
feet  and  ankles  swell.  The  scrotum  or  labia  and  the  dorsal  portions  of 
the  body  become  cedematous.  Later,  dropsical  effusions  may  appear  in 
the  serous  cavities,  peritoneal,  pleural,  and  pericardial.  CEdema  of  the 
glottis  and  lungs  may  develop,  the  patient  dying  of  asphyxia  unless 
promptly  relieved. 

Although  the  oedema  in  young  infants  may  be  only  moderate,  it  is 
rarely  absent,  and  careful  examination  of  the  extremities  and  sternum 
will  probably  reveal  some  pitting  on  pressure.  It  is  claimed  that  an 
increase  in  the  body  weight  shows  increased  water  in  the  tissues,  not 
revealed  by  inspection. 

The  pulse  in  children  does  not  often  show  the  high  arterial  tension 


374  DISEASES    OF    GENI  TO-URINARY    TRACT 

indicative  of  renal  disease  in  adults.  Neither  is  the  accentuation  of  the 
second  aortic  sound  so  noticeable.  The  pulse  is  often  rapid  and  irritable 
in  character,  the  cardiovascular  signs  depending  largely  upon  the  nature 
and  duration  of  the  antecedent  disease. 

Anaemia  appears  early  in  the  disease  and  is  most  marked  when  the 
nephritis  develops  in  a  later  stage  of  the  severer  acute  infections.  This 
is  especially  true  in  diphtheria. 

The  ever-impending  danger  in  acute  nephritis  is  uraemia .  Uraemic 
coma  or  convulsions  may  occur  late  in  the  disease  or  may  usher  in  the 
attack  as  a  first  indication  of  renal  insufficiency.  The  degree  of  uraemia 
is  at  all  thnes  an  index  of  the  gravity  of  the  disease.  Hebetude,  lethargy, 
and  impaired  vision  are  significant  forerunners  of  coma,  while  headache, 
vertigo,  restlessness,  delirium,  twitckings,  and  heightened  patellar  re- 
flexes are  indicative  of  impending  eclampsia. 

The  diagnosis  of  dropsy  due  to  cardiac  insufficiency,  with  passive 
renal  congestion,  should  not  be  difficult  after  careful  examination  of  the 
heart  and  urine.  If  the  patient  is  seen  for  the  first  time  in  the  more 
advanced  stage  of  acute  nephritis  with  a  normal  amount  of  urine,  little 
albumin,  and  low  specific  gravity,  chronic  interstitial  nephritis  may  be 
suspected,  but  the  history  of  the  acute  attack  would  clear  up  the  diag- 
nosis. 

The  prognosis,  always  grave,  is  darkened  by  the  decrease  in  the 
amount  of  urine,  the  increase  in  its  morbid  constituents,  and  the  develop- 
ment of  indications  of  uraemia.  The  occurrence  of  pulmonary  and  glottic 
oedema,  before  referred  to,  are  of  serious  import,  while  complications, 
such  as  pneumonia,  or  endocarditis  and  pericarditis,  greatly  lessen  the 
chances  of  recovery.  Especially  in  young  infants  are  such  complications 
fatal.  Early  recognition,  prompt  treatment,  and  intelligent  care  will 
limit  the  mortality  to  exceptional  cases. 

Treatment. — Prophylaxis  requires  the  promotion  of  excretion  in 
children  suffering  from  any  infectious  disease,  especially  scarlet  and 
typhoid  fevers,  diphtheria,  or  gastro-enteritis.  Upon  the  appearance  of 
the  first  evidence  of  oedema,  as  puffiness  of  the  eyes,  prompt  catharsis 
should  be  induced  by  calomel,  ipecac  and  soda,  while  thin  stools  should  be 
maintained  by  the  frequent  administration  of  salines.  The  congestion  of 
the  first  days  of  acute  nephritis  occasionally  shows  marked  relief  from 
the  application  of  ice-bags  to  the  lumbar  region.  This  is  applicable  only 
to  older  children,  as  is  also  the  use  of  dry  cups  over  the  kidneys.  For 
babies  a  mild  sinapism  or  warm  cataplasm,  sprinkled  with  mustard,  to 
the  lumbar  surface,  is  preferable.  Applications  of  turpentine  in  these 
cases  should  be  avoided ;  so,  also,  the  employment  of  all  drugs  that  favor 
renal  congestion, — as  carbolic  acid,  cantharides,  and  the  balsamic  and 
salicylate  group.  The  child  should  be  protected  from  cold,  overeating, 
and  fatigue.  The  etiologic  role  of  gastro-enteritis  among  infants  should 
be  remembered,  so  that  the  correction  of  digestive  disturbances  be  not 
neglected. 

It  is  safe  in  every  condition  of  coma  from  unknown  cause  to  induce 


ACUTE    NEPHRITIS  375 

prompt  purgation.  The  urine  should  always  be  examined,  though  cathe- 
terization may  be  necessary  to  secure  a  specimen.  For  collecting  the 
urine  of  infants  a  teacup  may  be  retained  under  the  genitals  by  a 
napkin,  with  a  little  dexterity.  Or  in  the  male  child  a  rubber  bag  may 
be  supported  by  tapes  passing  around  the  loins.  Ordinarily  the  child 
may  be  induced  to  urinate  by  the  application  of  the  cold  wet  hand  over 
the  bladder,  with  a  little  pressure. 

The  treatment  of  renal  insufficiency  consists  essentially  in  promoting 
vicarious  elimination  by  the  bowels  and  skin.  The  crippled  kidneys 
should  be  further  relieved  by  the  reduction  of  proteid  ingested  and  by 
limitation  of  muscular  activity,  reducing  metabolism  to  the  lowest  pos- 
sible degree.    The  child  should  be  kept  in  bed  between  blankets. 

The  oedema  is  a  contraindication  to  the  ingestion  of  a  large  quantity 
of  liuids,  as  in  high  albuminuria  the  kidneys  excrete  with  difficulty, 
the  tissues  of  the  body  becoming  waterlogged,  and  the  heart  over- 
burdened. Thirst  may  be  relieved  by  cracked  ice  and  small  drinks  fre- 
quently repeated.  Cream,  bread  and  butter,  rice  and  other  cereals,  and 
bland  vegetable  soups,  form  the  safest  dietary  as  long  as  oedema  persists. 
With  the  disappearance  of  oedema  and  an  increased  flow  of  urine,  the 
menu  may  be  more  generous  and  include  eggs,  milk,  fruits,  legumes, 
and  small  amounts  of  meat.  It  is  now  taught  that  there  is  no  ground  for 
the  former  general  belief  in  the  greater  safety  of  "  white"  meat.  The 
weight,  temperature  curve,  and  quality  of  pulse  should  be  daily  watched, 
as  by  them  may  be  determined  if  the  diet  is  adapted  to  the  excretory 
power  of  the  kidneys.  In  extensive  oedema  salt  should  be  restricted, 
since  it  favors  the  retention  of  water  in  the  tissues.  The  routine  prac- 
tice of  restricting  the  diet  to  large  quantities  of  milk,  with  the  copious 
administration  of  water,  for  its  presumed  effect  in  flushing  out  the 
kidneys,  is  particularly  pernicious  in  renal  insufficiency  with  large  drop- 
sical accumulations.  Later  in  the  disease,  when  the  renal  congestion  has 
somewhat  subsided,  as  indicated  by  the  increased  urination,  fluids  may 
be  given  with  good  effect.  In  acute  cases  all  stimulating  diuretics  are 
not  futile  but  injurious. 

The  development  of  uramiic  symptoms  demands  more  active  purgation 
and  diaphoresis.  The  latter  may  be  secured  by  dry  heat,  hot  baths,  or 
hot  packs.  Jaborandi  and  its  derivatives  are  contraindicated,  especially 
in  infants.  Calomel  and  jalap,  or  compound  jalap  powder,  are  useful. 
Hydragogue  cathartics  and  cream-of-tartar  lemonade  in  moderation  may 
replace  the  water.  For  eclamptic  attacks,  the  hot  pack  is  indicated,  with 
chloral  and  bromides  per  rectum.  The  hypodermic  use  of  morphine  or 
codeine  may  be  necessary  in  recurrent  convulsions.  The  coal-tar  prod- 
ucts should  not  be  used.  For  weak  heart  with  low  arterial  tension  digi- 
talis may  be  administered,  but  its  routine  use  in  all  cases  should  be 
discouraged. 

The  development  of  pulmonary  oedema  may  call  for  the  use  of  nitro- 
glycerin and  strophanthus,  with  dry  cupping  over  the  thorax,  and  if 
accompanied  by  high  arterial  tension,  venesection  of  the  median  basilic 


376  DISEASES    OP    GEXITO-URINARY    TRACT 

vein,  in  addition  to  the  above  treatment.  (When  blood  is  drawn  for  the 
relief  of  renal  engorgement,  it  should  be  taken  from  the  lower  ex- 
tremities. ) 

The  anaemia  of  convalescence  calls  for  the  use  of  iron,  Basham's 
mixture  preferably,  or  the  tincture  of  the  chloride,  in  moderate  doses. 
Rest  in  the  recumbent  position  and  protection  from  exposure  to  cold 
should  be  maintained  for  weeks  after  the  subsidence  of  acute  symptoms. 
When  practicable,  transfer  to  a  warm  and  equable  climate  is  recom- 
mended. 

Return  to  the  usual  dietary  should  be  very  gradual,  the  urine  being 
closely  watched.  Its  diminution  or  the  reappearance  of  morbid  elements 
calls  for  the  prompt  resumption  of  hygiene  according  to  the  principles 
previously  enumerated. 

CHRONIC   NEPHRITIS. 

Prolonged  venous  blood  stasis  in  the  kidney,  as  in  other  organs, 
eventually  produces  cell-  proliferation  and  hyperplasia  of  connective 
tissue.  This  is  followed  by  pressure  effects  on  the  epithelial  elements  of 
the  parenchyma  of  the  organ  due  to  contracting  interstitial  tissue.  Some 
recent  post-mortem  reports  of  infants  showed  only  vestiges  of  the  kidney 
as  the  result  of  cirrhotic  and  degenerative  changes.  As  has  been  seen, 
active  hyperemia,  from  whatever  cause,  with  its  increased  influx  of  in- 
fective or  toxic  material,  causes  changes  in  both  the  parenchyma  and 
stroma,  with  a  predilection  for  the  former,  so  may  passive  hyperemia 
cause  changes,  although  less  rapidly,  especially  in  the  stroma.  These 
structural  and  functional  changes  in  their  relation  to  each  other  and  in 
the  sequence  of  their  occurrence,  their  persistence  and  extent,  depend 
largely  upon  the  manner  of  onset,  also  the  extent  of  and  duration  of  the 
passive  hyperemia  through  which  they  are  induced. 

The  cause  of  this  passive  hyperemia  may  be  general  or  local,  as  from 
affections  of  the  heart  and  lungs  or  from  mechanical  pressure  of  new 
growths,  congestions,  or  any  condition  which  obstructs  the  renal  circu- 
lation on  the  venous  side. 

The  futility  of  the  claim  for  continued  independent  existence  of  a 
single  kidney  lesion  is  apparent ;  any  case  of  long  duration  would  fur- 
nish the  evidences  of  chronic  diffuse  nephritis.  Simply  for  convenience 
in  description,  the  division  of  chronic  nephritis  into  parenchymatous 
and  indurative  or  interstitial  is  made,  according  as  the  epithelium,  or 
stroma,  suffers  the  more  in  any  particular  case  at  the  time  of  investi- 
gation.* 

Chronic  nephritis  may  develop  so  insidiously  as  to  attract  no  atten- 
tion. The  child  may  show  underdevelopment  for  age,  recurrent  head- 
aches, restlessness,   fatigue   upon   slight  exertion,  moderate   oedema   or 

*  Chronic  nephritis  has  usually  been  regarded  as  of  infrequent  occurrence  in 
early  life.  The  probability,  however,  is  that  more  urinalyses,  and  more  exact 
methods  of  examination,  and  an  increased  number  of  post-mortems,  would  increase 
the  frequency  of  its  diagnosis. 


CHRONIC    NEPHRITIS  377 

digestive  disturbances  from  no  apparent  cause.  Some  or  all  of  these 
symptoms  may  subside  only  to  reappear  after  a  few  weeks  or  months 
with  increasing  intensity.  The  slight  dropsy  may  become  general,  with 
effusions  into  serous  cavities  and  threatening  symptoms  of  pulmonary 
oedema.  Examination  of  the  urine  shows  it  to  be  scanty,  of  high  specific 
gravity,  and  containing  all  varieties  of  casts  and  a  large  amount  of 
albumin.  Between  the  exacerbations  the  quantity  of  urine  increases 
with  lowering  specific  gravity  and  diminution  of  albumin. 

These  symptoms  may  have  been  preceded  months  or  even  years  by 
an  attack  of  acute  nephritis  or  an  obscure  history  of  dropsy  following 
an  acute  infectious  fever.  The  tendency  of  chronic  nephritis  is  to 
increase  in  the  persistency  of  its  symptoms,  with  developing  anaemia, 
asthenia,  and  shorter  intervals  of  relief,  until  invalidism  is  firmly  estab- 
lished. Uraemic  symptoms  may  develop  at  any  time  with  threatening  or 
actual  fatality. 

The  duration  of  the  disease  may  be  from  one  to  many  years,  if  not 
shortened  by  intercurrent  disorders,  the  patient  succumbing  at  last  to 
insufficiency  of  renal  function. 

The  prognosis  depends  upon  the  early  diagnosis  and  the  treatment. 
Very  few  cases  are  cured,  although  much  may  be  done  to  ameliorate  the 
condition  and  defer  the  fatal  termination. 

In  the  interstitial  variety  of  chronic  nephritis,  the  rarest  form  in 
childhood,  the  symptoms  usually  are  very  obscure  and  their  develop- 
ment gradual.  Among  those  regularly  characteristic  of  this  form  are 
cardiac  hypertrophy  and  increased  arterial  tension,  normal  or  increased 
quantity  of  urine  of  low  specific  gravity,  1.002  to  1.010,  with  little  or 
infrequent  albumin  or  casts  and  disturbance  of  vision  from  retinitis. — 
a  rare  occurrence  in  the  other  varieties  of  nephritis.  The  occurrence 
of  retinitis  may  be  the  first  intimation  of  renal  disturbance,  or  this 
result  may  occur  among  the  terminal  symptoms.  Heredity  undoubtedly 
has  a  place  in  the  etiology  as  have  also  rheumatism  and  syphilis.  As  its 
approach  is  most  insidious  its  duration  is  the  longest. 

The  diagnosis  is  difficult  and  depends  upon  the  findings  of  a  sys- 
tematic, long-continued  examination  of  the  urine,  with  the  classical 
symptoms  before  mentioned.  In  a  child  high  arterial  tension,  with  left 
ventricular  hypertrophy  not  compensatory  of  a  valvular  lesion,  should 
always  arouse  suspicion  as  to  its  renal  origin.  Instances  of  atheromatous 
arteries  in  young  children  are  not  wanting,  a  significant  fact  in  its  rela- 
tion to  cerebral  hemorrhage. 

The  prognosis  is  hopeless  as  to  the  renal  lesion,  although  with  due 
attention  to  hygiene  and  treatment,  life  may  continue  with  apparent 
comfort  for  many  years. 

The  value  of  a  knowledge  of  renal  disease  depends,  first,  upon  an 
early  recognition  of  the  morbid  tendency  of  the  individual ;  second,  upon 
the  alertness  in  discovering  the  earliest  indications  of  impaired  renal 
function;  third,  upon  the  intelligent  application  of  physiology  and 
hygiene  to  the  function  of  elimination  and  to  the  relief  of  the  affected 


378  DISEASES    OF    GENITO-URINARY    TRACT 

part;  fourth,  upon  successful  recognition  and  removal  or  amelioration 
of  the  exciting  cause.  The  same  general  principles  of  treatment  men- 
tioned in  the  acute  variety  apply  to  the  chronic  type  during  its 
exacerbations.  The  treatment  of  the  ever-prevailing  ansemia  as  well  as 
the  complications  and  crises  which  arise  during  its  course,  is  not  peculiar 
to  this  disease. 

Recently  surgery  has  offered  some  interesting  procedures,  such  as 
decapsulation,  scarification,  and  efforts  to  establish  collateral  circulation 
in  the  kidney.    These  are  at  present  sub  judice. 

Amyloid  degeneration  of  kidney  may  follow  renal  changes  under 
conditions  which  favor  amyloid  invasion  of  other  organs,  as  after  pro- 
longed suppurative  processes  of  bone,  lung,  and  other  tissues.  The 
diagnosis  is  made  from  the  presence  of  waxy  casts  in  the  urine,  with 
splenic  and  hepatic  enlargements. 

URIC   ACID. 

Probably  all  new-born  infants  have  more  or  less  uric  acid  crystals 
in  the  urinary  tract.  Post-mortems  of  the  new-born  very  commonly 
reveal  infarcts  in  the  straight  tubules  of  the  kidney.  On  section  of  the 
kidney  they  appear  as  brownish-red,  fan-shaped  areas.  Under  low 
magnifying  power,  these  areas  are  seen  to  be  engorged  with  crystalline 
bodies,  uric  acid  infarcts.  So  great  may  be  the  accumulation  that  the 
tubules  are  blocked  with  them  with  resultant  complete  anuria.  Under 
these  conditions  the  infant  may  die  within  the  first  week  without  having 
voided  urine. 

Uric  acid  crystals  are  commonly  seen  upon  the  diapers  of  young 
infants  as  reddish-brown  stains,  most  abundant  in  the  first  days  of  life, 
after  which  they  gradually  disappear  as  the  free  ingestion  of  liquor 
flushes  the  kidneys  and  aids  in  their  excretion.  The  presence  of  these 
crystals,  by  their  mechanical  irritation  in  the  renal  tubules,  pelves, 
ureters,  and  bladder,  causes  colicky  pains,  tenesmus,  frequent  micturi- 
tion, and  priapism. 

CALCULI. 

In  the  presence  of  colloid  material,  as  mucus  in  the  urinary  tract, 
the  uric-acid  granules  form  concretions  known  as  gravel  or  calculi. 
These  stones  in  infancy  and  childhood  are  largely  composed  of  uric 
acid  and  urates,  both  amorphous  and  crystalline,  but  may  be  mixed  with 
triple  phosphates  and  other  salts. 

Statistics  show  a  large  preponderance  of  renal  calculi  in  children 
over  adults.  When  we  consider  the  number  of  infants  who  escape 
careful  examination,  it  suggests  the  probability  of  the  still  greater  pre- 
ponderance of  gravel  disorders  in  early  life.  Calculi  may  be  formed 
in  the  pelvis  of  the  kidney  and  if  not  too  large  may  be  swept  into  the 
bladder  by  the  stream  of  urine.  In  either  situation  their  size  may  be 
augmented  until  symptoms  reveal  their  presence. 

A  calculus  as  large  as  a  cherry  has  been  found  in  the  bladder  of  a 


URINARY    CALCULI  379 

still-born  male  infant.  The  concretion  may  be  single  or  multiple, 
smoothly  rounded  or  irregularly  shaped,  with  roughened  surfaces. 

Vesical  calculi  are  found  in  male  children  twenty  times  as  frequently 
as  in  females,  the  short  distensible  urethra  allowing  freer  passage  while 
the  concretion  is  yet  small. 

That  the  formation  of  calculi  follows  an  heredity  has  long  been 
known.  Certain  families  of  gouty  and  rheumatic  diatheses  show  marked 
recurrence  of  this  trouble  in  successive  generations. 

Frequent  micturition  during  the  day,  without  nocturnal  incontinence, 
sudden  stoppage  of  the  stream  while  urinating,  difficult  micturition  with 
straining,  tenesmus,  and  pain  on  the  under  side  of  the  penis,  also  any 
symptoms  of  vesical  irritation  or  pain  in  the  region  of  the  bladder  while 
riding  over  rough  roads,  running,  jumping,  etc.,  are  suggestive  of  vesical 
calculus.  Severe  paroxysmal  pain  beginning  in  the  lumbar  region, 
radiating  towards  the  pubis,  with  retraction  of  the  corresponding  tes- 
ticle, may  indicate  the  passage  of  a  calculus  through  the  ureter.  Sud- 
den cessation  of  pain  occurs  when  the  stone  reaches  the  bladder.  Occa- 
sionally the  pain  may  be  so  severe  as  to  cause  collapse  or  even  convulsions. 
Dull,  aching,  persistent  pain  in  the  region  of  the  loins,  radiating  to 
other  parts  of  the  body — as  the  hips,  thighs,  bladder,  or  scrotum,  espe- 
cially after  active  or  violent  exercise,  with  alternating  excess  and  scanti- 
ness of  urine,  with  nausea  or  rigors — are  among  the  indications  of  stone 
in  the  pelvis  of  the  kidney,  too  large  to  engage  in  the  ureter. 

The  urine  in  any  of  these  conditions  is  acid,  of  high  specific  gravity, 
deeply  pigmented  and  smoky.  It  may  contain  albumin,  hyaline  and 
granular  casts,  cylindroids,  renal  and  vesical  epithelium,  blood,  and 
sometimes  pus. 

The  diagnosis  of  calculus,  in  spite  of  the  familiar  symptoms,  is  not 
unattended  with  difficulty.  Any  or  all  of  the  symptoms  may  be  produced 
by  other  conditions, — as  cystitis,  genital  irritation  from  phimosis,  re- 
tained smegma,  lumbricoids,  oxyurides,  or  any  cause  of  rectal  irritation, 
pyelitis,  or  appendicitis.  As  routine  urinalyses  becomes  more  general 
fewer  calculi  will  escape  detection.  The  X-ray  has  aided  in  diagnosis 
when  the  stone  is  of  considerable  size.  The  diagnosis  of  vesical  calculus 
may  be  positively  confirmed  only  by  the  use  of  the  sound,  which,  if  prac- 
ticable, should  be  introduced  with  the  patient  under  anaesthesia.  Keeping 
in  mind  the  sharper  curve  of  the  juvenile  urethra,  care  should  be  taken 
not  to  penetrate  the  posterior  wall  and  enter  the  ischiorectal  fossa  instead 
of  the  bladder. 

The  treatment  is  prophylactic  and  curative.  Infants  and  children, 
whether  from  heredity  or  other  cause,  who  show  a  tendency  to  uric- 
acidosis,  should  be  required  to  drink  freely  between  meals  alkaline 
waters,  as  Vichy  or  Lithia.  To  a  young  infant  a  grain  of  potassium 
acetate  or  citrate  may  be  administered  in  water,  after  nursing,  until  the 
urine  is  rendered  less  acid  and  the  diapers  are  free  from  stain. 

The  diet  of  older  children  should  be  non-stimulating,  consisting  of 
fish,  fresh  vegetables,  fruits,  proteids  and  fats  in  moderation,  avoiding 


380  DISEASES    OF    GEXITO-UFJNARY    TEACT 

the  excessive  use  of  carbohydrates  on  account  of  their  tendency  to  disturb 
digestion. 

The  passage  of  a  renal  calculus  through  the  ureter  may  be  facilitated 
by  heat  applied  over  the  lumbar-dorsal  region  or  by  hot  sitz-baths.  Mor- 
phine or  codeine  may  be  used  hypodermatically,  but  cautiously,  as  after 
the  extrusion  of  the  stone  extreme  narcotism  may  follow  its  heroic  ex- 
hibition. Chloroform  anaesthesia  is  admissible,  not  only  for  its  anal- 
gesic but  for  its  relaxing  effect  upon  the  tubal  spasm. 

The  presence  of  stone  in  the  bladder  or  kidney  calls  for  early  surgical 
interference  for  its  removal,  as  prolonged  irritation  will  result  in 
catarrhal  and  suppurative  conditions. 

PYELITIS — PYELONEPHRITIS  ;    PYONEPHROSIS. 

The  pelvis  of  the  kidney  may  become  infected  from  the  blood,  the 
urine,  or  from  suppurative  processes  in  adjacent  organs  and  tissues. 
Various  pyogenic  organisms  have  been  found,  including  the  typhoid, 
tubercle,  and  colon  bacilli.  Pyelitis  is  frequently  associated  with 
pyelonephritis  and  ureteral  obstruction  from  calculus  or  congenital 
malformations,  and  it  may  result  eventually  in  the  destruction  of  the 
kidney. 

Uric  acid  crystals  by  mechanical  irritation  may  induce  catarrhal  in- 
flammation of  the  pelvis  of  the  kidney,  which  may  become  purulent  with 
mixed  infection.  In  the  same  way,  hydronephrotic  accumulations  may 
become  purulent. 

Pyelitis  may  follow  any  of  the  infectious  fevers,  or  it  may  result 
from  infection  through  the  bladder  or  urethra.  Its  development  in  the 
course  of  enterocolitis  in  diapered  infants  is  of  special  interest  in  con- 
nection with  the  colon  bacillus  as  showing  the  peregrinations  of  that 
bacterium.  Reports  show  that  nearly  all  of  these  cases  have  occurred 
among  girl  babies.  For  similar  reasons  they  are  more  subject  to  pye- 
litis from  gonorrhceal  vulvovaginitis.  Cystitis  is  probably  the  most 
common  source  of  infection.  It  may  be  caused  by  the  ingestion  or 
external  application  of  such  agents  as  turpentine,  cantharides,  copaiba, 
carbolic  acid,  etc. 

The  disease  is  more  common  in  infancy  than  was  formerly  supposed, 
as  pyuria,  the  diagnostic  symptom,  has  in  the  past  been  frequently  over- 
looked or  attributed  to  mysterious  origin. 

Traumatism  and  exposure  to  cold  may  act  as  causes.  During  or 
following  acute  infectious  diseases  pyuria  may  be  the  only  symptom  of 
this  disease,  and  the  fever,  if  present,  attributed  to  the  primary  disease. 
The  attack  is  usually  ushered  in  by  a  sharp  chill,  followed  by  consider- 
able pyrexia,  even  105°  to  106°  F.  (40.5°-41°  C. ) ,  with  headache,  anorexia, 
and  vomiting.  The  temperature  is  usually  irregular,  chills  recurring 
at  intervals  of  a  few  days  with  all  the  indications  of  severe  infection. 
There  may  be  rapid  loss  of  weight.  The  urine  is  scanty,  high  colored, 
sometimes  bloody,  and  contains  pus  in  varying  amounts,  with  epithelium 
of  caudate  variety,  and,  if  nephritis  coexist,  tube  casts.    Unless  relieved 


PYELITIS  381 

early,  symptoms  of  the  consequent  cystitis  are  added  to  those  of  the 
original  disease. 

A  sudden  disappearance  of  the  pus  may  be  indicative  of  obstruction 
in  the  ureter  by  a  calculus,  blood-clot,  or  inspissated  mucus,  which,  being 
overcome  by  increasing  pressure,  allows  the  reappearance  of  pus  in  a 
copious  discharge,  resembling  the  rupture  of  an  abscess. 

The  disease  may  become  chronic  and,  with  occasional  acute  exacerba- 
tions, run  a  course  of  months  or  even  years. 

Dull  pain  in  the  dorsal  lumbar  region  is  suggestive  of  calculus.  Care- 
ful examination  of  children's  urine,  in  all  cases  of  pyrexia,  may  not 
infrequently  reveal  an  unsuspected  pyelitis  and  help  to  lessen  the  number 
of  unclassified  fevers.  Catheterization  of  the  ureters  is  of  special  value 
in  differentiation  from  cystitis  and  to  determine  the  unilateral  or  bilat- 
eral character.    The  question  of  a  stone  may  be  settled  by  skiascopy. 

From  cystitis,  diagnosis  may  be  made  by  the  acid  urine,  caudate 
pelvic  epithelium,  larger  amount  of  pus,  the  presence  of  casts  from  the 
kidneys,  and  absence  of  vesical  pain  and  tenesmus. 

The  prognosis  depends  upon  the  etiology.  Prhnary  uncomplicated 
pyelitis  should  yield  promptly  to  treatment  in  a  few  weeks.  If  tuber- 
culous, the  prognosis  is  grave,  and,  if  associated  with  malignant  neo- 
plasms, hopeless. 

Treatment. — Acute  uncomplicated  pyelitis  requires  rest  in  bed,  fluid 
diet  (especially  milk),  free  catharsis  by  calomel,  ipecac,  and  soda,  and  by 
diuretics,  particularly  potassium  citrate,  sufficient  to  neutralize  the  acid- 
ity of  the  urine.  The  patient  must  be  supported,  and  tonics  may  be 
necessary,  with  iron*  for  the  anamiia.  Urotropin  is  indicated  for  its 
antiseptic  effect  and  methylene-blue  is  sometimes  useful  in  obstinate 
cases.  The  diagnosis  of  the  presence  of  a  calculus  should  call  for  early 
surgical  interference. 

CYSTITIS. 

Cystitis  is  by  no  means  rare  in  childhood.  It  occurs  more  frequently 
in  girls  than  boys.  It  may  range  in  severity  from  a  mild  transient 
catarrh  to  the  most  intractable  chronic  form,  with  destructive  lesions 
and  hyperplastic  changes  in  the  mucous  and  submucous  tissues. 

Etiology. — The  most  frequent  cause  of  hypera?mia  of  the  bladder  is 
exposure  to  cold.  Infection  may  be  due  to  a  variety  of  micro-organisms, 
among  which  are  the  coli  communis,  typhoid  and  tubercle  bacilli,  the 
gono-,  staphylo-,  and  streptococci.  The  most  common  are  the  colon 
bacillus  and  gonococcus.  The  routes  of  infection  may  be  by  way  of  lym- 
phatics, blood-vessels,  ureters,  urethra,  or  by  contiguity  from  neighboring 
organs. 

Inflammation  of  the  bladder  is  a  common  accompaniment  of  ne- 
phritis, pyelitis,  and  diabetes  mellitus,  and  is  frequently  a  complication 
or  sequel  of  the  acute  infectious  fevers.  Uric  acid  calculi,  overdisten- 
tion,  retention  from  any  cause,  and  traumatism,  are  among  the  frequent 
exciting  causes.    Both  trauma  and  infection  may  follow  catheterization. 


382  DISEASES    OF    GENITO-TJKINAKY    TRACT 

Symptoms. — The  most  prominent  symptoms  are  deep-seated  pain,  fre- 
quent micturition  with  ardor  urina?,  tenesmus,  and  rise  in  temperature, 
occasionally  preceded  by  a  chill.  Early  in  the  attack  the  urine  is  high 
colored,  turbid,  acid,  concentrated,  and  may  contain  blood,  pus,  mucus, 
large  numbers  of  vesical  epithelial  cells,  and  bacteria.  Later  the  urine 
may  be  neutral  or  alkaline,  or  become  so  shortly  after  passing.  It  may 
be  very  turbid  and  ropy.  More  advanced  cases  show  the  urine  putrid 
and  alkaline  from  ammoniacal  decomposition.  The  child  is  fretful  and 
irritable. 

In  prolonged  cases  there  may  be  exacerbations  and  remissions  with 
loss  of  weight  and  aneemia. 

Diagnosis. — The  diagnosis  is  plain.  Examination  of  the  urine  is 
sufficient  to  establish  the  nature  of  the  affection  and  usually  the  etiology. 

Prognosis. — The  prognosis  depends  upon  the  infecting  agent  and 
complications.  A  chronic  pyelonephritis  must  never  be  lost  sight  of. 
Chronicity  of  this  affection  calls  for  careful  cystoscopic  exploration  for 
vesical  lesions,  as  ulcers,  adventitious  growths,  etc.  Tuberculosis  renders 
the  prognosis  grave.  Acute  simple  cystitis  should  recover  inside  of  two 
weeks. 

Treatment. — In  acute  cystitis  the  child  should  be  put  to  bed.  Saline 
laxatives  should  be  administered  with  a  neutralizing  diuretic,  such  as 
acetate  or  citrate  of  potassium.  The  child  should  be  made  to  drink  large 
quantities  of  water.  The  diet  should  be  reduced  in  quantity  and  con- 
fined to  liquids.  Hot  sitz-baths  and  fomentations  may  relieve  the  pain 
and  tenesmus.  In  gonorrheal  infection,  or  when  there  is  much  pus,  the 
bladder  should  be  washed  out  daily  with  weak  solutions  of  boric  acid, 
potassium  permanganate,  creolin,  or  lysol.  Urotropin  every  four  hours 
is  valuable  where  there  is  decomposition  or  fermentation,  and  salol  may 
be  used  in  the  absence  of  nephritis.  Severe  pain  or  tenesmus  calls  for 
the  use  of  hyoscyamus  or  belladonna  by  mouth  or  rectal  suppository. 
Eestlessness  and  insomnia  may  require  bromides.  The  presence  of  stone, 
new  growths,  and  tumors  should  relegate  the  case  to  the  surgeon. 

PERINEPHRITIS — PARANEPHRITIS  ;    EPINEPHRITIS. 

Perinephritis  occurs,  with  or  without  suppuration,  in  the  fibrous  and 
adipose  tissues  which  surround  the  kidneys.  It  is  of  interest  in  children 
because  of  the  resemblance  of  its  symptoms  to  those  of  other  inflamma- 
tions common  at  this  age,  and  the  frequently  mistaken  diagnosis. 

Paranephritis  may  be  secondary  to  suppurative  processes  in  adjacent 
structures  as  pyelonephritis,  appendicitis,  peritonitis,  abscess  of  the  liver, 
spleen,  or  intestines,  or  it  may  be  due  to  a  septic  embolus  from  a  remote 
region.  A  number  of  cases  have  been  called  primary  because  of  the 
absence  of  any  known  source  of  infection.  Traumatism,  exposure  to 
cold,  and  constipation,  appear  to  have  been  contributory  causes  in  some 
instances.  The  symptoms  are  those  of  acute  inflammation  of  moderate 
intensity, — chill,  fever  of  irregular  type,  local  pain  and  tenderness  accom- 
panied by  swelling  in  the  affected  lumbar  and  ileocostal  areas.     Later 


PERINEPHRITIS  383 

there  is  dulness  on  percussion,  with  evidenees  of  infiltration  of  the  sub- 
cutaneous  tissues.  Occasionally,  swelling  and  tenderness  are  found  at 
the  pubis  or  the  upper  inner  aspect  of  the  thigh  from  the  burrowing  of 
pus.  The  thigh  of  the  affected  side  is  slightly  Hexed  and  resists  extreme 
extension  but  is  freely  movable  in  other  directions.  Pain  is  occasionally 
referred  to  the  abdomen,  groin,  and  knee.  When  suppuration  occurs  the 
presence  of  a  fluctuating  tumor  may  sometimes  be  made  out  and  con- 
firmed by  the  aspirating  needle.  The  tumor  is  not  movable  nor  does  the 
urine  present  any  abnormality  unless  there  is  some  involvement  of  the 
kidney.  Then  the  urine  may  contain  pus,  albumin,  and  casts.  Resolu- 
tion may  occur  in  from  ten  days  to  ten  weeks.  Even  longer  time  may 
ensue  before  recovery. 

The  pus  may  burrow  into  the  peritoneal  cavity  with  fatal  peritonitis, 
or  it  may  perforate  the  diaphragm  and  enter  the  pleural  cavity.  It 
may  burrow  extensively  between  the  muscles  and,  escaping  through 
the  sacrosciatic  notch,  appear  at  the  buttocks.  The  adjacent  kidney  may 
suffer  from  pressure  or  become  involved  in  the  extensive  suppuration. 
The  prognosis,  however,  is  surprisingly  good  considering  the  gravity  of 
the  lesion  and  the  danger  of  involving  important  organs. 

Differential  Diagnosis. — Perinephritis  may  be  mistaken  for  a  gravi- 
tation abscess  from  a  tuberculous  spine,  but  the  absence  of  angular 
deformity  of  the  spine  and  the  rapid  course  would  serve  to  differentiate. 
A  blood  examination  should  show  leukocytosis.  Operations  for  supposed 
perityphlitis  have  been  made  in  which  the  appendix  was  found  normal 
with  a  retroperitoneal  accumulation  of  pus  from  a  perinephritic  inflam- 
mation. It  differs  from  hip  disease  in  its  more  acute  onset,  absence  of 
other  evidences  of  tuberculosis,  greater  mobility  of  the  limb,  absence  of 
hip- joint  pain  or  tenderness  on  pressure,  rapid  development,  and  early 
termination. 

From  typhoid  fever,  for  which  it  is  sometimes  mistaken  in  an  early 
stage,  the  diagnosis  must  be  made  by  the  more  acute  onset  with  chill,  the 
absence  of  hebetude,  the  localization  of  pain  and  tenderness,  the  negative 
reaction  to  Widal  test,  the  absence  of  Eberth's  bacillus  in  the  urine,  and 
the  presence  of  leucocytosis. 

Treatment. — For  early  abortive  treatment,  the  patient  should  be  put 
to  bed,  the  bowels  opened  freely,  and  hot  poultices  or  ice-bags  (according 
to  age)  applied  to  the  affected  side.  As  soon  as  pus  is  located,  drainage 
should  be  secured  by  free  incision. 

HYDRONEPHROSIS. 

Hydronephrosis  is  due  to  an  obstruction  to  the  flow  of  urine  in  the 
ureter,  bladder,  or  urethra,  with  a  resulting  distention  of  ureter  or  renal 
pelvis,  or  both.  It  may  be  either  unilateral  or  bilateral.  It  is  occa- 
sionally congenital  and  a  cause  of  dystochia. 

Among  the  causes  may  be  mentioned  phimosis,  imperforate  urethra, 
vesical  calculus,  stenosis  at  ureteral  orifice,  abnormal  insertion  of  ureters 
into  the  bladder,  valvular  folds  or  growths  in  the  linings  of  ureters, 


384  DISEASES    OF    GENI TO-URINARY    TRACT 

tortuosity  of  these  tubes,  pressure  from  adjacent  tumors,  strangulation 
from  nephroptosis,  obstruction  from  calculus,  parasite,  or  a  blood-clot 
in  tube  or  pelvis,  and  angular  insertion  of  ureter  in  pelvis.  Occasionally 
careful  post-mortem  fails  to  reveal  any  cause. 

The  retention  of  urine  may  be  complete  or  intermittent,  dependent 
on  the  nature  of  the  obstruction.  The  pressure  of  accumulated  urine 
induces  distention  of  the  entire  tract  above  the  obstruction.  Occasionally 
this  is  most  noticeable  in  the  ureter,  which  may  equal  in  size  the  large 
intestine.  The  accumulating  pressure  in  the  renal  pelvis  and  calices 
may  destroy  the  parenchyma,  leaving  but  a  thin  shell  of  cortical  tissue, 
the  resulting  tumor  reaching  enormous  proportions. 

The  retained  urine  in  these  cysts  may  change  to  a  clear  fluid,  acid  or 
neutral,  presenting  but  few  urinary  characteristics. 

The  symptoms  are  sometimes  absent  and  when  present  are  variable, 
depending  upon  the  cause  and  the  extent  of  involvement.  Single  hydro- 
nephrosis may  be  suspected  from  the  presence  of  an  abdominal  tumor, 
which  produces  bulging  and  flatness  on  percussion,  in  the  region  of  the 
kidney.  The  diagnosis  is  not  always  easy,  and  differentiation  may  be 
made  from  malignant  growths  by  the  absence  of  cachexia  and  by  cathe- 
terization. From  cysts  of  other  abdominal  organs,  parasitic  cysts  of  the 
kidney,  also  from  pyelonephrosis,  catheterization  of  the  ureter  should 
aid  in  diagnosis. 

The  treatment  is  the  relief  of  the  causative  disorder,  when  possible. 
If  the  other  kidney  be  unaffected,  surgical  operation  occasionally  affords 
good  results.  The  majority  of  congenital  hydronephrotics  die  during  the 
first  year. 

BALANITIS,    POSTHITIS,    AND   URETHRITIS    IN    MALE    CHILDREN. 

Balanitis,  an  acute  inflammation  of  the  mucous  membrane  oi  the 
glans,  and  posthitis,  an  inflammation  of  the  preputial  mucosa,  are  not 
uncommon  either  in  infancy  or  childhood.  They  may  be  caused  by 
any  irritation,  as  from  retained  smegma,  uric  acid,  traumatism,  mas- 
turbation, and  general  lack  of  cleanliness.  As  preputial  stenosis  inter- 
feres with  proper  cleansing  of  the  glans,  prophylaxis  should  include 
dilatation  and  retraction  or  circumcision  in  early  infancy.  The  mucous 
membrane  is  reddened,  swollen,  tender,  and  bathed  in  purulent  secretion. 
Not  infrequently  oedema  of  the  prepuce  is  extensive,  phimosis  marked, 
and  urination  difficult,  with  some  smarting  and  "  ballooning"  of  the 
foreskin.  The  treatment  is  simple  irrigation  with  some  antiseptic  solu- 
tion, as  boric  acid,  permanganate  potassium,  or  bichloride  (1:1000) 
solution.  This  may  be  done  by  introducing  the  nozzle  of  the  syringe  into 
the  preputial  orifice  and  distending  the  foreskin  so  that  all  parts  may 
be  reached  by  the  fluid.  This  should  be  repeated  several  times  a  day. 
If  the  inflammation  be  intractable  and  the  phimosis  marked,  the  foreskin 
should  be  slit  up  the  dorsal  surface.  Circumcision  is  not  advisable 
during  the  acute  inflammation. 

Simple  urethritis  occurs  in  childhood  and  rarely  in  early  infancy. 


BALANITIS  385 

It  may  be  due  to  the  extension  of  a  balanitis,  introduction  of  foreign 
substances,  traumatisms  from  Halls  and  blows,  irritating  urine,  or  the 
passage  of  a  sharp  calculus.  Usually  the  inflammation  is  confined  to  the 
fossa  navicularis.  There  is  a  purulent  discharge,  more  or  less  pain  on 
micturition,  and  priapism.  The  adjacent  glands  may  become  indurated 
and  extensive  balanitis  may  aggravate  the  condition  and  modify  the 
treatment.  The  treat  mod  should  consist  of  free  catharsis  by  salines,  and 
neutralizing  the  urine  by  the  use  of  bicarbonate  of  soda  with  a  plentiful 
supply  of  water.  Irrigation  is  rarely  necessary,  except  in  unusually 
obstinate  cases.  Microscopic  examination  of  the  discharge  should  be 
made  in  all  cases  to  assure  differentiation  from  specific  urethritis,  the 
symptoms  of  which  in  some  instances  are  identical  with  those  of  the 
simple  form. 

Specific  urethritis  is  due  to  gonococcal  infection,  the  source  of  which 
is  always  a  human  gonorrhoea,  as  this  infection  is  confined  to  man. 

Burning  pain  at  the  end  of  the  penis  on  urination  is  often  the  first 
symptom  of  urethral  gonorrhoea.  The  discharge  from  the  meatus  of 
yellow,  greenish  pus,  sometimes  slight,  is  the  characteristic  symptom. 
Upon  examination,  this  is  found  to  contain  the  gonococci  of  Neisser. 
Untreated,  the  discharge  may  continue  for  months,  gradually  diminish- 
ing in  cpiantity  after  the  first  week.  Ardor  urinae,  priapism,  and  even 
chordee,  are  the  most  distressing  symptoms.  Lymphadenitis  of  the  in- 
guinal glands  may  rarely  proceed  to  suppuration.  Cystitis  is  an  occa- 
sional sequel.  Prostatitis  rarely  occurs  in  childhood,  owing  to  the  unde- 
veloped condition  of  that  gland.  Orchitis  and  epididymitis  are  not 
infrecpient.  Arthritis  in  the  ankles  and  knees  should  be  watched  for 
and  conjunctivitis  guarded  against. 

Prognosis. — No  age  seems  exempt  from  gonorrhoea,  as  cases  have  been 
reported  in  the  new-born,  infected  from  the  birth-passage.  Stricture, 
as  in  the  adult,  may  follow  urethritis  in  children. 

An  early  diagnosis  is  important,  that  the  disease  may  be  aborted 
while  yet  the  infection  is  confined  to  the  anterior  urethra  and  before  the 
bacteria  have  found  lodgement  in  the  crypts  of  the  deeper  structures. 
To  this  end  a  free  flow  of  alkalinized  urine  must  be  encouraged  by  the 
copious  ingestion  of  water  with  potassium  citrate  or  acetate  in  fre- 
quently repeated  doses.  The  child  should  be  kept  in  bed,  regardless  of 
symptoms,  with  extreme  precautions  as  to  the  spread  of  the  infection. 
The  diet  should  be  non-stimulating  and  confined  principally  to  milk. 

Irrigations,  such  as  potassium  permanganate  (1:3000)  or  saturated 
solution  of  boric  acid,  if  used  in  the  early  stage,  should  be  confined  to 
the  anterior  urethra  by  compression  of  the  penis  at  its  middle  portion, 
and  used  only  after  a  urination.  In  advanced  or  subacute  gonorrhoea 
irrigation  without  the  introduction  of  a  catheter  may  be  made  by  repeat- 
edly filling  the  bladder  by  means  of  a  fountain  syringe,  with  a  blunt  tip 
pressed  against  the  meatus. 

The  swelled  testicles  always  require  the  dorsal  decubitus,  with  the 
scrotum  supported  by  a  bandage  placed  across  the  thighs.    Hot  fomenta- 

25 


386  DISEASES   OF   GENITO-URINARY  TRACT 

tions  or  poultices,  with  the  administration  of  codeine  by  mouth  or  sup- 
pository, may  be  needed  for  the  relief  of  pain.  The  bowels  should  be 
kept  open.  Guaiacol,  five  to  fifteen  per  cent.,  in  olive  oil,  applied  once  or 
twice  a  day  to  the  swollen  scrotum,  is  often  very  valuable. 

SIMPLE   VULVOVAGINITIS. 

At  birth  a  viscid  secretion  is  frequently  found  between  the  lips  of 
the  vulva.  "With  ordinary  care  and  cleanliness  this  disappears  in  a  few 
days.  It  may  persist,  however,  in  the  victims  of  malnutrition  and  occa- 
sionally a  purulent  discharge,  with  all  the  symptoms  of  inflammation, 
may  follow.  The  discharge  may  become  quite  profuse  and  excoriation 
may  be  produced,  with  pain  upon  micturition  from  involvement  of  the 
urethra.  Occasionally  this  affection  is  persistent,  resisting  ordinary 
methods  of  treatment. 

Not  infrequently,  in  older  infants  and  children,  vulvovaginitis  de- 
velops from  which  there  may  be  a  profuse  mucopurulent  discharge.  The 
parts  are  reddened,  the  vulva,  hymen,  and  vaginal  mucosa  are  swollen 
and  inflamed.  Microscopic  examination  of  the  discharge  shows  a  variety 
of  pus  organisms,  strepto-,  staphylo-,  and  pneumococcus,  with  bacillus 
coli  communis  predominating.  The  disease  is  evidently  communicable, 
as  it  extends  through  families  and  institutions.  Neglect  of  cleanliness, 
scabies,  traumatisms,  irritation  from  clothing,  masturbation,  worms,  and 
irritating  urine  are  mentioned  as  exciting  causes.  It  is  most  commonly 
seen  in  poorly  nourished  children  and  in  those  of  lowered  vitality  fol- 
lowing acute  infections.  These  catarrhs  show  a  marked  predilection  for 
the  rhachitic,  lymphatic,  and  tubercular  diatheses. 

The  disease  is  never  fatal,  its  complications  rarely  extending  further 
than  the  adjacent  glands,  which  occasionally  suppurate. 

Careful  attention  to  hygiene,  with  daily  irrigations  of  the  affected 
mucosa  with  warm  saturated  solution  of  boric  acid,  will  usually  effect 
a  cure  in  from  one  to  four  weeks.  The  inflamed  labia  should  be  dusted 
with  a  powder  and  separated  by  a  pledget  of  cotton  or  gauze.  The  urine 
should  be  rendered  less  irritating  by  the  free  use  of  water  or  a  weak 
dilution  of  potassium  citrate.  The  bowels  should  be  kept  free  by  citrate 
of  magnesia.  Tonics  of  iron  or  cod-liver  oil,  with  generous  diet,  are 
necessary  to  overcome  the  tendency  to  lowered  vitality. 

SPECIFIC   VULVOVAGINITIS. 

A  more  virulent  form  of  vulvovaginitis  is  that  due  to  infection  by 
the  gonococcus.  This  infection  among  infants  and  children  is  either 
alarmingly  on  the  increase  or  else  it  was  wofully  overlooked  by  former 
clinicians.  Numerous  reports  of  epidemics  in  hospitals  and  institutions, 
as  well  as  from  private  practice,  all  attest  the  virulence,  intractability, 
and  wide  range  of  complications  and  sequela?  of  infections  from  the 
Neisser  organism.  The  ocular  conjunctiva  and  the  mucosa  of  the  geni- 
tals, more  particularly  that  of  the  vulva  and  vagina,  show  a  remarkable 
susceptibility  to  this  infection.    Especially  is  this  true  of  infants  under 


SPECIFIC    VULVOVAGINITIS  387 

three  years  of  age.  Other  tissues  occasionally  afford  ports  of  entry  to 
the  circulation, — as  the  umbilicus,  the  oral,  nasal,  or  pharyngeal  mucosa, 
and  accidental  lesions  of  the  integument,  since  suppurative  phlegmo- 
nous endocardial  and  arthritic  inflammations  are  reported  with  no  evident 
lesions  of  the  genito-urinary  tract.  It  is  probable  that  an  unobserved 
stomatitis  may  have  served  as  a  primary  focus  in  some  of  these  cases. 
The  usual  mode  of  infection  is  by  direct  contact,  although  among  infants 
and  children  there  is  ample  reason  to  believe  that  it  is  frequently  carried 
by  intermediate  agents;  hence  all  discharges  of  a  suspicious  character, 
from  whatever  source,  should  be  immediately  destroyed, — if  on  cloths, 
by  fire;  if  on  garments,  by  bichloride  solution  (1  :  1000).  The  parent, 
nurse,  and  physician  must  be  constantly  alert,  and  the  conscientious  use 
of  soap  and  water,  with  nail  brush  and  lysol,  should  be  insisted  upon. 

The  peculiar  odor  of  gonorrhceal  vulvovaginitis  in  diapered  infants 
suffering  from  diarrhceal  disorder,  in  which  the  colliquative  stools  mask 
the  discharge,  may  be  the  first  intimation  of  this  infection. 

The  period  of  incubation  may  be  from  two  to  ten  days.  The  appear- 
ance of  the  discharge  may  be  preceded  by  a  rise  in  temperature,  which 
is  frequently  masked  by  some  pre-existing  disease.  The  child  in  pre- 
viously good  health  will  exhibit  distinct  symptoms  of  malaise,  anorexia, 
and  elevation  of  temperature,  frequently  preceded  by  rigor  or  chilliness. 
In  hospitals,  whence  the  largest  number  of  reports  are  derived,  the 
victims  are  patients  admitted  for  other  disorders ;  so  that,  occurring  in 
post-operative,  post-typhoid,  and  tuberculous  children,  or  as  a  complica- 
tion to  some  other  acute  disorder,  the  initial  symptoms  too  frequently 
are  misinterpreted,  incurring  the  loss  of  a  few  days  of  grave  significance 
to  the  non-infected  infants  in  the  same  ward.  No  other  organism  is 
capable  of  producing  so  enormous  an  amount  of  pus  from  so  limited  an 
area  in  so  short  a  time.  The  pus  is  yellow,  often  with  a  greenish  tinge, 
and  leaves  a  characteristic  stain  upon  the  linen,  which  it  stiffens.  Local 
heat  and  tenderness  are  common,  although  occasionally  the  child  expe- 
riences no  further  discomfort  than  pruritus.  Smarting  and  tenesmus 
on  urination  are  present  when  the  infection  invades  the  urethra.  This, 
strangely,  occurs  less  frequently  in  the  infant  than  in  the  adult.  Occa- 
sionally, however,  painful  micturition  is  the  first  symptom  to  attract 
attention  to  the  local  disorder.  The  acute  period  of  the  disease  is  self- 
limiting,  the  period  of  most  active  pus  formation  extending  from  ten  to 
twenty  days.  The  extent  of  the  immediate  injury  depends  upon  the 
nature  of  the  tissue  involved,  the  vulvovaginal  mucosa  showing  but  little 
damage  as  compared  with  the  structures  of  the  eye,  cardiac  intima,  and 
peritoneum.  Peritonitis,  either  local  or  general,  is  an  occasional  compli- 
cation and  is  fatal  in  twenty  per  cent,  of  the  reported  cases.  Endocar- 
ditis is  one  of  the  most  serious  of  the  gonococcus  lesions,  while  arthritis 
and  metastatic  abscesses  may  result  in  fatal  general  pyaemia.  The  far- 
reaching  effects  of  gonorrhoeal  infection,  however,  are  seen  in  its  ten- 
dency to  recrudescence  upon  slight  provocation ;  so  that  successive  at- 
tacks may  involve  the  entire  genito-urinary  tract,  sterilizing  the  repro- 


388  DISEASES   OF   GENITO-URIXARY   TEACT 

ductive  organs,  and  leaving  a  heritage  of  pelvic,  vesical,  and  renal 
morbidity  which  ruins  the  mature  life. 

Diagnosis. — The  diagnosis  is  made  by  the  microscope,  in  the  discovery 
of  the  gonococcus  of  Xeisser. 

Treatment. — The  first  indication  in  treatment  is  to  destroy  the  spe- 
cific micro-organism  by  any  means  not  injurious  to  the  tissues.  Hence 
early  diagnosis  is  important  so  that  applications  may  be  made  before  the 
deeper  structures  are  involved.  Superficial  irrigation,  even  with  solu- 
tions of  undoubted  bactericidal  power,  fail  to  reach  the  harboring  sulci 
and  rugas  of  the  tumefied  mucosa  unless  most  carefully  and  thoroughly 
applied.  For  this  a  speculum  must  be  used,  and  the  parts  swabbed 
from  above  downwards  with  a  two  per  cent,  solution  of  nitrate  of  silver, 
ten  per  cent,  protargol,  or  fifteen  per  cent,  argyrol,  after  which  a  pledget 
of  cotton  moistened  with  saturated  boric  acid  solution  should  be  left  in 
situ.  It  may  even  be  necessary  to  pack  the  vagina,  or  in  advanced  cases 
to  treat  the  endocervical  mucosa.  The  treatment  should  be  repeated  three 
or  four  times  the  first  day,  after  which  the  application  may  be  made 
once  a  day  with  a  thorough  irrigation  with  potassium  permanganate 
(1:  2000)  every  two  or  three  hours.  Under  this  treatment  the  discharge 
diminishes  rapidly,  with  subsidence  of  the  acute  symptoms.  These  re- 
appear with  active  pus  formation,  if  there  is  interruption  in  the  treat- 
ment. The  complete  sterilization  of  the  invaded  tract  will  often  tax  the 
practitioner's  ingenuity  to  the  utmost,  for  even  after  the  cessation  of  all 
purulent  discharge  with  negative  smears  for  several  successive  days,  the 
treatment  is  stopped  at  the  risk  of  a  recrudescence  of  all  the  symptoms. 

There  is  no  known  means  of  determining  that  the  disease  has  termi- 
nated. Some  physicians  discharge  the  case  as  cured  if  at  the  end  of  two 
weeks  from  the  disappearance  of  all  symptoms  successive  smears  prove 
negative. 

From  the  first  symptom  the  vulva  should  be  covered  by  a  sterile 
pad  of  gauze  or  cotton  retained  by  a  diaper ;  the  patient  must  be  isolated 
and  specialized  in  every  detail  of  nursing,  as  care  of  dietary,  bed- 
clothing,  utensils,  and  thermometer.  Sterilization  and  isolation  must  be 
the  watchword  in  the  strictest  sense.  Nurses  and  parents  must  be  made 
to  realize  the  gravity  of  the  infection  with  which  they  are  dealing. 
Gonorrhoea!  infection  will  undoubtedly  soon  receive  its  proper  recogni- 
tion as  one  of  the  most  virulent  and  dangerous  of  the  infective  diseases, 
and  secure  the  necessary  legislation  for  the  protection  of  the  innocent 
that  is  now  accorded  to  some  other  common  but  less  formidable  disorders. 

PHIMOSIS   AND   ADHERENT   PREPUCE. 

The  normal  coherence  of  the  prepuce  and  the  glans  penis  at  birth 
may,  from  lack  of  proper  attention,  continue  throughout  infancy  into 
childhood.  Whenever  seen,  this  condition  should  be  relieved  by  dilata- 
tion and  retraction,  which  operation  may  be  aided  by  the  introduction 
of  a  probe  between  the  prepuce  and  glans;  sweeping  it  around  in  such  a 
manner  as  to  release  adhesions.     If  there  be  much  phimosis  the  inelas- 


PHIMOSIS  389 

ticity  of  the  foreskin,  especially  in  older  children,  may  make  this  ex- 
tremely difficult  or  unadvisable  because  of  the  resultant  paraphimosis. 
Frequently,  however,  repeated  efforts  at  dilatation  and  retraction  will 
prove  successful  in  apparently  unpromising  cases.  The  manipulation 
should  be  attended  with  aseptic  detail,  aided  by  a  little  oil  or  vaseline. 
Occasionally  circumcision  will  be  found  necessary,  not  only  for  cleanli- 
ness, but  to  release  the  incarcerated  glans.  Splitting  the  prepuce  on  its 
dorsal  surface  writh  a  sharp-pointed  bistoury,  along  a  grooved  director 
introduced  under  the  foreskin,  produces  equally  good  results  with  the 
former  operation.  The  mucous  membrane  should  be  secured  to  the  in- 
tegument at  the  raw  edges  with  interrupted  catgut  sutures.  Before 
suturing  some  operators  trim  off  the  redundant  corners  on  either  side. 

The  phimosis  may  be  atrophic  in  which  there  is  a  deficiency  of  tissue, 
the  scanty  prepuce  pressing  tightly  on  the  glans,  which,  during  erection, 
shows  slightly  through  the  small  opening ;  or  hypertrophic  when  the  re- 
dundant tissue  is  elongated  into  a  pendulous  point,  writh  extreme, 
unyielding  stenosis. 

Some  of  the  immediate  effects  of  extreme  phimosis,  especially  if 
coherence  between  the  two  layers  of  mucosa  be  firm,  is  constant  pressure 
upon  the  glans  during  the  normal  congestion  of  micturition,  with  retar- 
dation in  growth  and  development  of  the  organ.  Frequent  desire  for 
micturition,  with  obstruction  to  the  flow,  causes  straining,  resulting 
in  some  instances  in  hernia,  hydrocele,  and  prolapsus  ani.  The  retained 
urine  produces  irritation,  which  invariably  leads  to  much  handling  of 
the  parts  and  masturbation.  Decomposition  of  the  urine,  with  the  re- 
tained smegma,  lights  up  a  balano-posthitis  which  may  possibly  involve 
the  urethra  and  lead  to  vesical  catarrh.  This  may  be  the  beginning  of 
a  pyelonephritis  of  later  years.  It  is  not  strange  that  constant  local 
irritation  during  the  developing  period  should,  through  the  delicate 
reflex  mechanism  of  the  reproductive  system,  affect  to  a  remarkable 
degree  the  development  and  function  of  organs  and  tissues  apparently 
remote.  Nor  that  the  equilibrium  of  the  nervous  system,  unstable'  as  it 
is  before  the  full  establishment  of  inhibition,  should  exhibit  many 
anomalous  and  strange  phenomena.  The  disorders  attributed  to  prepu- 
tial abnormalities  are  legion.  A  few  may  be  mentioned :  urinary  in- 
continence and  retention,  restlessness,  night  terrors,  epilepsy,  headache, 
amaurosis,  strabismus,  chorea,  convulsions,  pseudoparalysis,  hysteria,  in- 
digestion, diarrhoea,  marasmus,  with  innumerable  tics,  habits,  and  many 
psychologieal  disturbances. 

The  female  prepuce,  formed  by  the  junction  of  the  nympha?,  is 
usually  at  birth  more  or  less  adherent  to  the  glans  clitoris.  If  this  inti- 
mate adhesion  persist  throughout  childhood,  the  sensitive  glans  is  con- 
stricted, interfering  with  the  circulation  so  as  to  cause  hyperannia,  irrita- 
tion with  resultant  masturbation,  and  a  train  of  psychic  and  neurotic 
disturbances  similar  to  many  of  those  enumerated  above.  It  is  claimed 
that  this  condition  may  result  in  hypererethism  with  erotic  tendencies, 
or  in  extreme  sexual  apathy  in  later  life.     Eminent  authorities  recom- 


390  DISEASES   OF   GENITO-URINARY  TRACT 

mend  a  release  of  the  clitoris  from  a  too  closely  enveloping  prepuce  as 
essential  to  its  normal  growth  and  freedom  from  irritation. 

That  the  condition  described  as  an  abnormality  is  as  frequent  in 
occurrence  or  as  far-reaching  in  its  morbid  effects  in  the  girl  as  preputial 
defects  are  in  the  boy,  is  highly  improbable.  Undoubtedly,  occasional 
instances  occur  of  serious  derangement  in  the  girl,  for  which  the  phy- 
sician should  be  on  the  alert. 

ENURESIS — INCONTINENCE   OF   URINE. 

Enuresis  is  a  functional  disorder  in  which  the  retention  of  the  urine 
is  only  partially  under  control  of  the  patient.  Complete  incontinence  is 
extremely  rare  at  any  age,  and  is  probably  due  to  some  malformation 
or  to  a  total  paralysis  of  the  vesical  sphincter.  A  case  is  reported  in 
which  one  ureteral  orifice  opened  into  the  urethra,  resulting  in  a  con- 
tinuous oozing  of  urine.  Urinary  continence  is  only  relative  in  degree, 
and  it  is  seen  in  the  youngest  infant  to  a  certain  extent,  the  contents  of 
the  bladder  being  evacuated  at  intervals.  The  mechanism,  including  the 
bladder,  its  muscles,  and  nerve  supply,  constitute  an  apparatus  which 
operates  automatically  to  a  certain  extent  independent  of  higher  nerve- 
centres,  during  infancy.  With  increase  in  vesical  capacity  the  inter- 
vals between  its  evacuations  lengthen.  To  the  purely  reflex  mech- 
anism of  bladder,  sphincter,  lumbar  centre,  and  nerves  afferent  and 
efferent,  there  is  added,  with  increasing  age,  the  influence  of  the  in- 
hibitory centre  in  the  cerebral  cortex.  As  inhibition  develops  more 
rapidly,  and  is  perfected  earlier  in  some  individuals  than  in  others,  so 
the  degree  of  urinary  continence  varies  in  different  infants  at  the  same 
age.  Educational  efforts  in  their  developing  effects  upon  higher  centres 
of  inhibition  show  early  results  in  the  control  obtained  over  the  reflex 
function  of  urination.  Arrested  cerebral  development  illustrates  this  in 
the  frequency  of  enuresis  in  idiots. 

The  normal  operation  of  this  function  may  be  interfered  with  by  a 
great  variety  of  disorders,  either  general  or  local,  acting  alone  or  in  com- 
bination. So  that  incontinence  may  be  due  to  abnormal  conditions  of 
the  bladder,  of  the  urine,  of  the  nervous  system,  or  of  different  organs 
and  tissues  which  may  influence  the  function  through  reflex  disturbances. 

Intolerance  of  the  bladder  from  congestion  may  be  due  to  the  pres- 
ence of  a  foreign  body,  such  as  a  calculus,  uric  acid,  sand,  worms,  etc., 
or  to  cold  or  the  irritating  character  of  the  urine  from  concentration, 
hyperacidity,  bacteria,  sugar,  or  the  products  of  inflammatory  processes 
in  the  kidney;  or  chemical  decomposition  of  the  urine,  constipation, 
rectal  tenesmus,  fissure  and  polypi,  irritation  due  to  worms,  phimosis, 
preputial  adhesions  both  in  boys  and  girls,  vulvovaginitis,  masturbation, 
or  any  cause  of  genital  hyperemia  may  induce  vesical  intolerance. 
Small  size  of  the  bladder  is  sometimes  found,  although  this  condition 
is  probably  a  result  as  well  as  a  cause  of  frequent  micturition. 

The  nervous  mechanism  involved  in  bladder  control  may  be  im- 
paired by  disease,  traumatism,   or  pressure,  so  that  the  nice  balance 


ENURESIS  391 

between  the  action  of  bladder  contraction  and  sphincter  control  is  dis- 
turbed. Spinal  disease  or  injury  may  interrupt  conduction  of  nerve 
influence  from  the  inhibitory  centre  in  the  cortex.  The  local  neurosis 
may  be  only  a  part  of  a  general  neurasthenia,  so  that  malnutrition  or  ex- 
haustion from  general  septic  condition,  or  convalescence  from  acute 
disease,  may  have  incontinence  of  urine  as  a  result. 

Treatment. — In  the  treatment,  the  cause  of  vesical  irritation  should 
be  sought  and  relieved  by  appropriate  measures.  Examination  of  the 
urine,  both  chemically  and  microscopically,  should  never  be  omitted,  as 
a  most  frequent  cause  of  vesical  intolerance  is  here  found.  Concentrated 
highly  acid  urine  calls  for  dilution  and  neutralization  by  copious  drink- 
ing of  alkaline  waters.  If  the  incontinence  be  nocturnal,  the  ingestion 
of  water  should  be  restricted  towards  bedtime.  Bromides,  belladonna, 
and  hyoscyamus  are  well-known  obtunders  of  vesical  hyperesthesia  and 
should  be  given  preferably  towards  the  latter  part  of  the  day.  Coffee, 
tea,  and  alcoholic  stimulants  must  be  strictly  interdicted.  The  clothing 
of  the  child  should  be  such  as  to  protect  from  the  chilling  of  the  surface, 
and  the  diet  must  be  non-stimulating  and  regulated  so  as  not  to  exceed 
the  limit  of  perfect  digestion.  Excess  of  carbohydrates,  especially 
sweets,  may  be  more  injurious  than  a  moderate  amount  of  proteids. 
Irritability  of  spinal  nerve-centres,  as  seen  in  the  exaggerated  re- 
flexes of  the  lower  portion  of  the  body,  such  as  cremasteric,  gluteal, 
patellar,  and  ankle,  would  suggest  the  use  of  bromides  and  ergot.  The 
general  neurasthenia  with  accompanying  anaemia  requires  specially  ap- 
propriate hygiene,  of  which  cold  bathing,  general  and  local,  forms  an 
important  part,  with  tonics  and  hemic  restoratives,  such  as  arsenic  and 
iron.  The  tincture  of  the  chloride  has  a  reputation  as  specific  in  vesical 
disorders.  The  use  of  the  interrupted  current  is  highly  regarded  by 
many  practitioners,  one  moist  electrode  being  applied  to  the  perineum 
and  the  other  to  the  sacral  or  suprapubic  region.  The  practice  of  intro- 
ducing electrodes,  sounds,  etc.,  into  the  urethras  of  young  children  should 
be  discouraged  when  any  other  measure  can  be  substituted. 

Local  irritative  conditions  of  the  rectum  and  genitals  should  receive 
attention.  Preputial  .stenosis  should  be  corrected,  and  the  glans  and 
corona  freed  either  by  circumcision  or  dilatation  and  retraction.  The 
clitoris  should  be  released  from  an  adherent  prepuce.  Balanitis,  urethri- 
tis, or  vulvovaginitis  should  receive  special  attention.  The  anal  sphinc- 
ter should  be  stretched  for  fissure, — a  procedure  usually  requiring  a 
general  anesthetic.  The  rectum  should  be  freed  from  polypoid  growths 
and  thread-worms. 

Since  the  vesical  trigone  is  its  most  sensitive  portion,  the  position  of 
the  child  may  be  changed  with  benefit,  as  by  elevating  the  foot  of  the  bed 
or  compelling  him  to  lie  on  his  side  or  abdomen.  In  addition  to  the 
above,  other  procedures  will  suggest  themselves  according  to  the  pathol- 
ogy of  the  special  case. 

An  adjuvant  to  all  therapeutic  measures  is  the  systematic  training  of 
the  child.    The  prevention  of  the  habit  is  of  paramount  importance,  since 


392  DISEASES   OF   GEXITO-URIXAKY  TRACT 

correction,  when  once  established,  is  most  difficult  even  after  the  removal 
of  all  obvious  causative  factors.  Evacuation  of  both  bladder  and  rectum 
before  going  to  bed  should  be  observed.  The  child  should  be  taken  up 
to  urinate  at  least  once,  preferably  early,  in  the  night.  He  must  be 
constantly  encouraged  to  overcome  the  habit,  but  never  by  fear  of  pun- 
ishment. The  early  development  of  self-control  by  tactful  teaching  is 
of  the  highest  importance,  and  constant  watchfulness  must  be  the  rule 
on  the  part  of  parents  and  physician  against  the  recurrence  of  morbid 
conditions  productive  of  enuresis.  The  majority  outgrow  the  habit  by 
the  seventh  year,  and  it  rarely  extends  beyond  puberty. 

CRYPTORCHIDISM UNDESCENDED    TESTICLE. 

As  previously  stated,  occasionally  at  birth  one  or  both  testicles  are 
absent  from  the  scrotum,  the  descent  having  been  arrested  within  the 
abdomen  or  at  some  point  below  the  internal  inguinal  ring,  often  in  the 
inguinal  canal,  where  it  may  be  felt  as  a  small  tumor.  In  the  majority 
of  cases  its  descent  will  be  accomplished  without  interference.  The 
question  of  surgical  intervention  depends  upon  the  fact  that,  if  long 
incarcerated,  pressure  in  its  malposition  not  only  arrests  its  growth  but 
degenerative  changes  may  occur. 

Operation  may  be  postponed  as  long  as  there  is  evidence  of  progress 
of  the  organ  through  the  canal,  as  indicated  by  its  changed  position. 

The  possibility  of  hernial  contents,  a  common  accompaniment  of 
arrested  descent,  should  be  remembered,  as  the  diagnosis  of  hernia  and 
application  of  a  truss  is  not  infrequent.  This  may  occasion  not  only 
much  discomfort  but  positive  injury  to  the  gland.  The  prolonged  dis- 
tention, too,  of  the  inguinal  canal,  favoring  the  development  of  subse- 
quent hernia  from  its  patulous  condition,  is  an  argument  in  favor  of 
early  surgical  correction. 

HYDROCELE. 

Hydrocele  occurs  quite  frequently  in  the  infant.  It  is  stated  that  in 
only  ten  per  cent,  of  post-mortems  of  infants  has  the  processus  vaginalis 
been  found  closed  at  birth.  Any  undue  collection  of  fluid  in  the  infant 's 
peritoneal  cavity  might  result  in  hydrocele  in  the  remaining  ninety  per 
cent. 

Hydrocele  consists  of  a  collection  of  fluid  in  the  tunica  vaginalis,  and 
may  appear  in  the  scrotum  in  free  communication  with  the  abdominal 
cavity,  when  it  is  termed  congenital  hydrocele.  The  testicle  will  be 
felt  behind  the  accumulation  of  fluid.  Change  in  position  and  slight 
taxis  will  cause  a  return  of  the  fluid  to  the  peritoneal  cavity.  Contin- 
uous pressure  from  a  truss  over  the  external  inguinal  ring  will  obliterate 
the  communicating  canal.  The  canal,  however,  may  have  been  already 
obliterated  at  Poupart's  ligament,  so  that  the  fluid  cannot  return  to  the 
abdominal  cavity.  This  is  known  as  the  infantile  form,  as  it  is  the  most 
common  in  infancy  and  childhood. 

Another  form,  known  as  hydrocele  of  the  cord,  is  found  above  the 


HYDROCELE  393 

scrotum ;  the  lower  portion  of  the  canal  having  been  obliterated,  the 
upper  end,  still  patulous,  is  freely  communicable  with  the  peritoneal 
cavity.  It  usually  fills  the  inguinal  canal  and  is  frequently  associated 
with  hernia.     It  is  easily  reduced  by  pressure. 

Encash  <l  hydrocele  of  the  cord  differs  from  the  last  named  only  by 
the  closure  of  its  abdominal  end,  the  cyst  appearing  as  a  small  oblong 
tumor  in  or  just  below  the  inguinal  canal.  Vaginalitis  may  serve  as  an 
explanation  for  the  encysted  variety.  It  may  be  mistaken  for  an 
enlarged  lymphatic  gland,  from  which  it  differs  in  consistency,  or 
for  an  undescended  testicle,  from  which  it  may  be  diagnosed  by  the 
presence  of  the  testicle  in  the  scrotum.  From  a  hernia  it  is  distin- 
guished by  the  termination  of  the  tumefaction  before  it  reaches  the 
internal  ring,  and  also  by  the  non-increase  in  size  upon  the  infant's 
crying  or  coughing.  Water  in  the  scrotum  shows  translucency  when 
viewed  through  an  opaque  tube  pressed  against  the  tense  tissues.  Hernia 
renders  the  sac  opaque.  This  is  a  test  which  should  never  be  omitted. 
There  is  occasionally  a  gurgling  on  pressure  when  the  hernial  sac 
contains  a  loop  of  the  intestine. 

The  treatment  of  infantile  and  encysted  forms  of  hydrocele  is  by 
aspiration  by  means  of  a  hypodermic  syringe,  or  puncture  with  a  small 
trocar,  allowing  the  fluid  to  flow  into  the  cellular  tissue  whence  it  is 
quickly  absorbed.  Usually  one  withdrawal  of  fluid  is  sufficient,  but  if 
not,  the  operation  should  be  repeated.  This  rarely  fails  to  effect  a  cure. 
In  older  children  an  obstinate  hydrocele  will  frequently  yield  to  appli- 
cations of  collodion  or  tincture  of  iodine  and  the  internal  administration 
of  potassium  iodide.    , 

HYDROCELE  IN  GIRLS. 

A  tumor  of  the  labia  majora  or  of  the  inguinal  canal  is  suggestive 
of  hydrocele  in  girls.  It  is  to  be  differentiated  from  inguinal  or  puden- 
dal hernia,  a  rare  condition  in  girls,  by  the  usual  points  of  differentia- 
tion. From  vulvovaginal  cysts  and  from  abscess  of  Bartholini's  gland, 
by  the  absence  of  pain,  redness,  and  inflammatory  symptoms. 

Hydrocele  in  girls  is  rarely  seen,  and  when  found  should  be  treated 
as  in  the  other  sex. 


CHAPTER   XI 
DISEASES    OF    THE    NERVOUS    SYSTEM 

CONVULSIONS — ECLAMPSIA  ;     SPASMS 

Muscular  spasms  are  disorderly  reflex  acts  involving  one  or  more 
muscles  or  groups  of  muscles.  The  term  convulsion  is  applied  to  spasms 
which  involve  a  large  number  of  voluntary  muscles  and  may  include 
the  entire  motor  system.  Spasm  may  occur  in  unstriped  as  well  as  in 
voluntary  muscle  and  is  usually  employed  to  designate  a  local  disturb- 
ance, as  vesical,  sphincteric,  and  laryngospasm. 

Whether  a  convulsion  be  the  result  of  an  overflow  of  motor  impulse, 
a  discharge  of  stored  energy,  or  an  explosion  of  nervous  force,  the 
clinical  fact  is  evident  that  infancy  is  peculiarly  susceptible  to  this 
form  of  motor  disturbance.  The  percentage  of  frequency  during  the 
first  quinquennium  is  shown  by  the  following :  About  45  per  cent,  of  all 
cases  occur  in  the  first  six  months  of  life ;  22  in  the  second  six  months ; 
25  in  the  second  year ;  5  in  the  third ;  2  in  the  fourth ;  1  in  the  fifth. 

It  has  been  claimed  that  in  infancy  the  motor  ganglion  cells  show 
greater  susceptibility  to  irritation.  On  the  other  hand,  it  has  been  shown 
that  excitation  of  nerves  and  muscles  in  the  earliest  infancy  (the  first 
five  weeks  of  life)  is  induced  only  by  very  strong  electrical  currents,  and 
even  with  these  the  contractions  are  slow.  All  observers  agree  that  in 
the  evolution  of  nerve  function  the  higher  or  inhibitory  centres  are  the 
last  to  develop.  After  the  removal  of  the  cerebrum,  convulsions  have 
been  induced  in  lower  animals  by  irritation  of  the  pontobulbar  area. 

With  the  development  of  the  inhibitory  centres  in  the  cortex  the 
tendency  to  convulsive  phenomena  rapidly  diminishes,  so  that  after  the 
fifth  year  eclampsia,  not  resulting  from  a  brain  lesion,  is  somewhat 
rarely  seen. 

An  undoubted  predisposition  to  eclamptic  seizures  is  attributable  to 
hereditary  influences,  as  in  neurotic,  alcoholic,  gouty,  rheumatic,  and 
tubercular  family  histories.  Rhachitic  infants,  also,  show  increased  ner- 
vous irritability  with  retarded  development  of  inhibition.  Although 
producing  similar  phenomena,  the  exciting  causes  of  convulsive  attacks 
differ  widely  in  importance  as  to  the  gravity  of  their  significance.  These 
causes  may  be  reflex,  toxic,  or  anatomic.  The  reflex  causes  result  from 
peripheral  irritations  of  the  gastro-intestinal  tract, — as  undigested  ar- 
ticles of  food  or  intestinal  parasites ;  from  genital  lesions ;  from  the 
presence  of  adenoids,  or  foreign  bodies  in  the  ear;  from  the  effects  of 
burns  or  cold  to  the  surface  of  the  body;  from  fright,  excitement, 
fatigue,  or  from  anything  causing  protracted  or  severe  pain. 
394 


CONVULSIONS  395 

Among  the  toxic  causes  are  the  acute  infections,  some  drugs  and 
chemical  agents,  uramiia,  and  acute  or  chronic  indigestion. 

The  anatomic  causes  include  any  condition  involving  structural 
change -in  the  brain,  intracranial  pressure — as  from  hydrocephalus  or 
tumors — abscesses,  hemorrhages,  embolism,  thrombosis,  or  meningitis. 

The  precipitation  of  a  convulsion  may  be  due  to  two  or  more  of  these 
exciting  causes,  as  in  the  familiar  gastro-enteritis,  accompanied  by  the 
absorption  of  toxins,  also  the  infection  of  whooping-cough,  with  asphyx- 
iation and  possible  intracranial  hemorrhage. 

In  many  instances  the  exact  operation  of  the  exciting  cause  is  not 
known.  Sudden  reduction  of  the  volume  of  blood  within  the  cranium 
will  frequently  induce  eclampsia.  On  the  other  hand,  intense  cerebral 
congestion  is  known  to  produce  the  same  effect,  so  that  a  depressed  or 
distended  fontanelle  may  precede  or  accompany  a  convulsion. 

Convulsions  rarely  occur  without  some  prodromal  symptoms,  such  as 
muscular  twitchings  of  the  extremities,  facial  grimaces,  restlessness, 
pallor,  or  nausea,  which  the  experienced  eye  readily  interprets  as  evi- 
dences of  disturbed  equilibrium. 

No  further  indications  of  eclampsia  may  be  seen  for  hours,  or  at  all; 
or  they  may  be  quickly  followed  by  ocular  symptoms,  such  as  conjugate 
deviation,  lateral  or  upward,  with  dilatation  of  the  pupils  and  a  fixed 
and  staring  expression  of  the  eyes;  the  nostrils  dilate,  respiration 
becomes  audible,  rigidity  of  the  entire  body  develops,  with  slight  retrac- 
tion of  the  head  and  spine ;  cyanosis  supervenes,  the  jaw  is  set,  fre- 
quently upon  the  tongue,  and  a  frothy  secretion  issues  from  the  lips. 
The  rigidity  may  last  from  one  to  several  seconds,  or  may  be  absent.  It 
is  replaced  or  followed  by  a  series  of  rhythmic  contractions  which  may 
involve  the  entire  trunk  and  limbs,  or  may  be  confined  to  certain  groups 
of  muscles,  unilateral  or  bilateral,  and  are  most  apparent  in  the  flexors. 
The  contractions  are  sharp  and  jerky,  and,  when  general,  may  be  so 
violent  as  to  cause  injury  from  contact  with  surrounding  objects.  The 
force  and  frequency  of  the  clonic  spasms  decrease  gradually  until  ap- 
parently from  exhaustion  they  cease  altogether.  This  cycle  is  usually 
completed  in  from  one  to  five  minutes,  occasionally  extending  over  a 
longer  period.  During  the  entire  attack  consciousness  is  more  or  less 
in  abeyance,  and  a  deep  stupor  or  coma  often  supervenes.  All  general 
eclamptic  seizures  are  clonic  in  character,  the  so-called  tonic  stage  con- 
sisting of  rhythmic  spasms  so  rapid  that  the  intervals  are  inappre- 
ciable. 

Diagnosis. — As  all  convulsions  are  merely  symptomatic  of  some  mor- 
bid condition,  the  diagnosis  consists  in  the  differentiation  of  the  under- 
lying  cause.  The  history  of  the  case  frequently  affords  a  clue.  In  the 
absence  of  any  aid  from  this  source,  as  in  the  sudden  seizure  of  a  patient 
seen  for  the  first  time,  a  thorough  examination  will  be  needed.  The 
temperature  should  be  taken,  as  pyrexia  would  suggest  the  onset  of 
an  acute  infection,  while  its  absence  would  exclude  the  probability  of  a 
meningeal   inflammation.      Pupillary   inequality   or   disturbed   reaction 


396  DISEASES    OF    THE    NERVOUS    SYSTEM 

would  suggest  intracranial  lesion,  with  further  corroboration  by  tension 
of  the  fontanelle  and  the  condition  of  the  retinal  vessels.  Spasticity  or 
paralysis,  unilateral  or  bilateral,  may  indicate  grave  cerebral  lesion.  In- 
spection may  show  lesions  or  traumatisms  causing  peripheral  irritation. 
Puffiness  of  the  eyes  or  oedema  of  the  legs  would  lead  to  examination  of 
the  urine  for  renal  disease.  Palpation  and  catheterization  may  show  an 
overdistended  bladder.  Tympanitic  distention  of  the  abdomen,  with 
examination  of  the  stools  or  vomitus,  might  furnish  evidence  of  the 
cause  arising  from  the  digestive  tract.  Throat  lesions  and  skin  eruptions 
would  suggest  the  onset  of  an  acute  exanthem.  Enlargement  of  the  liver 
and  spleen  might  indicate  malarial  infection,  of  which  the  convulsion 
represents  the  rigor.  Auscultation .  and  percussion  of  the  chest  might 
furnish  signs  of  a  developing  pneumonia, 

The  prognosis  obviously  depends  upon  the  underlying  cause.  If  the 
convulsion  be  the  initial  symptom  of  an  acute  infectious  disease  it  prob- 
ably will  not  recur,  having  the  same  significance  as  the  initial  rigor. 
If  it  occur  during  the  course  of  an  established  exanthem,  its  import  is 
more  serious  as  indicative  of  a  complication,  possibly  cerebral,  or  it  may 
be  a  terminal  symptom  of  an  acute  or  chronic  disease.  If  cerebral  lesions 
or  toxaemia  be  excluded,  the  probabilities  are  that  the  convulsions  are  but 
the  expression  of  peripheral  irritation,  by  far  the  commonest  cause  in 
infancy,  and  of  which  gastro-intestinal  irritation  constitutes  a  large 
percentage.  The  convulsion  itself  is  of  minor  importance  as  regards 
danger  to  life,  although  rare  cases  have  been  recorded  in  which  death 
occurred  in  a  primary  convulsion  from  asphyxiation  or  apoplexy,  so  that 
the  possibility  should  never  be  lost  sight  of.  The  danger,  however  in- 
significant the  exciting  cause  may  be,  lies  chiefly  in  the  possibility  of 
some  damage  to  the  cerebral  structures  far-reaching  in  its  consequences. 
Another  danger,  which  compels  a  guarded  prognosis,  is  that  this  con- 
vulsion may  prove  to  be  the  first  of  a  series  of  attacks  which  ultimately 
lead  to  an  established  epilepsy  in  an  infant  with  marked  predisposition, 
hereditary  or  acquired.  Statistics  show  that  fifty  per  cent,  of  the  cases 
of  convulsions  in  infancy  are  followed  in  later  life  by  serious  neuroses, 
such  as  epilepsy,  petit  mat,  somnambulism,  chorea,  melancholia,  and 
migraine. 

Treatment. — An  attack  of  convulsions  may  be  aborted,  if  anticipated 
in  time  by  the  premonitory  symptoms,  by  the  prompt  removal  of  a  pe- 
ripheral irritation.  A  sharp  and  prompt  purgative  is  rarely  contraindi- 
cated.  Calomel,  ipecac,  and  soda  may  be  given  in  doses  of  one  or  two 
grains  (0.065-0.13  Gm.)  of  the  first  and  last-mentioned  drugs,  with  one- 
eighth  to  one-fifth  of  a  grain  (0.008-0.013  Gm.)  of  ipecac,  to  be  repeated 
every  hour  for  three  or  four  doses.  The  last  dose  should  be  followed  an 
hour  later  by  two  teaspoonfuls  of  castor  oil.  A  full  enema  of  normal  salt 
solution  should  precede  all  medication.  The  child  should  be  given  a  hot; 
bath.  110°  F.  (43°  C),  or  preferably  a  hot  pack  of  the  same  temperature. 
A  turkish  towel  wrung  out  in  hot  water  should  envelop  the  patient  from 
neck  to  heels.    Meanwhile  the  head  should  be  kept  cool  by  an  ice-bag  or 


EPILEPSY  397 

compresses  wrung  out  in  cold  water.  A  tablespooni'ul  of  ground  mustard 
in  the  five-gallon  bath,  or  a  little  dry  mustard  sprinkled  over  the  towel 
pack,  will  promote  the  determination  of  blood  to  the  surface.  Bromides 
and  chloral  may  be  administered,  by  mouth  or  rectum,  in  full  doses, 
every  two  hours,  if  necessary.  In  obstinate  cases,  where  one  convulsive 
seizure  follows  another  in  quick  succession,  chloroform  may  be  given  by 
inhalation  sufficient  to  control  the  eclampsia.  In  case  of  failure  to 
interrupt  the  convulsions  by  the  above  means,  hypodermic  injection  of 
morphine,  one-fiftieth  to  one-twentieth  of  a  grain  (0.0013-0.003  Gm.), 
may  be  given  and  repeated  in  three  hours  if  necessary.  If  the  gums  be 
swollen  from  erupting  teeth,  free  lancing  will  secure  local  depletion  with 
occasionally  prevention  of  the  threatened  eclampsia.  Whatever  the  treat- 
ment be,  gentleness  to  secure  the  confidence  of  the  child  and  the  co-opera- 
tion of  the  parents  is  a  great  desideratum.  With  a  known  or  suspected 
predisposition  to  eclampsia,  the  best  of  hygienic  conditions  and  food  suit- 
able to  the  digestive  capabilities  of  the  child  are  indicated.  He  should  be 
relieved  of  all  exciting  or  debilitating  influences  and  requirements, 
whether  of  the  school  or  the  home. 

EPILEPSY. 

Epilepsy  is  characterized  by  a  recurrence  of  seizures  in  which  there 
is  loss  of  consciousness  with  convulsions  of  greater  or  less  severity,  from 
no  apparent  cause.  The  series  of  attacks  may  begin  at  any  period  of 
life,  and  although  the  diagnosis  of  epilepsy  is  not  easy  in  infancy,  many 
cases  are  known  to  have  their  origin  at  this  period.  Post-mortems  of 
epileptics  show  no  common  anatomic  lesion,  and  many  show  none  at  all. 
Statistics  from  a  large  number  of  cases  show  that  fourteen  per  cent,  have 
their  origin  in  the  first  five  years  of  life,  and  more  than  twelve  per  cent, 
in  the  first  three  years.  Intrauterine  and  birth  injuries  not  infrequently 
result  in  confirmed  epilepsy.  Heredity  unquestionably  plays  an  impor- 
tant role  in  the  etiology.  Various  competent  observers  have  placed  the 
responsibility  of  heredity  upon  a  history  of  ancestral  epilepsy,  other 
neuroses,  syphilis,  or  tuberculosis  in  from  forty-five  to  sixty-five  per  cent, 
of  all  cases.  In  considering  this  phase,  it  should  be  remembered  that  a 
large  proportion  of  the  progency  of  neurotics,  alcoholics,  syphilitics,  and 
degenerates  fortunately  die  in  infancy. 

Among  the  many  other  assigned  causes  may  be  mentioned  trauma- 
tism, the  exanthems,  metallic  poisons,  hemorrhages,  sunstroke,  disorders 
of  the  pubescent  period,  masturbation,  intestinal  parasites,  undigested 
food,  severe  fright, — in  fact,  anything  that  has  a  tendency  to  excite 
convulsions  or  establish  the  habit. 

Epileptic  attacks,  although  varying  widely  in  the  degree  and  inten- 
sity of  clinical  manifestations,  are  divided,  according  to  the  difference 
in  onset  and  period  of  duration,  into  two  general  classes  known  as  major, 
or  grand  mat,  and  minor  epilepsy,  or  petit  mal. 

A  major  epileptic  seizure  is  distinguishable  from  an  attack  of  severe 
simple   convulsions   only  by  the   preceding   aura   and   the    initial   cry 


398  DISEASES    OF    THE    NERVOUS    SYSTEM 

(present  in  less  than  fifty  per  cent,  of  all  cases),  and  a  greater  tendency 
to  somnolence  which  follows  the  seizures. 

The  cry  is  particularly  shrill  and  startling,  sometimes  being  due  to 
fright  and  at  others  only  to  unconscious  spasm  of  the  respiratory  mus- 
cles. The  aura,  a  prodrome  of  the  seizure,  may  precede  it  by  a  few 
seconds  or  even  minutes  and  may  consist  of  one  or  more,  of  a  great 
variety  of  sensations  and  impressions.  Perhaps  the  most  common  in 
children  is  an  epigastric  distress  passing  up  to  the  pharynx.  There  may 
be  a  sensation  of  coolness,  as  of  a  breeze  blowing  on  some  part  of  the 
body,  a  peculiar  odor  or  taste,  queer  sounds  as  of  ringing  in  the  ears, 
or  hissing  like  the  escape  of  steam.  There  may  be  visual  disturbances, 
as  diplopia,  muscge  volitantes,  or  distinct  images  as  of  a  face  or  other 
object.  Whatever  one  of  these  or  of  many  other  sensations  be  present, 
the  same  is  usually  repeated  at  the  beginning  of  each  attack,  so  that  the 
patient  soon  learns  its  significance  as  a  warning.  Dilatation  of  the 
pupils  is  always  present  as  the  first  eclamptic  expression.  The  con- 
vulsive phenomena  do  not  differ  from  those  due  to  peripheral  irritation 
and  show  similar  variations. 

The  seizures  known  as  petit  mat  resemble  the  major  attacks  in  their 
conformity  to  the  three  essentials  in  the  definition,  namely,  loss  of  con- 
sciousness, muscular  spasm,  and  periodicity.  The  unconsciousness  may 
be  evident  only  as  a  temporary  aberration,  a  transient  interruption  to 
the  current  of  ideas  attested  by  a  momentary  arrest  of  speech  or  occupa- 
tion, which  is  resumed  without  the  child's  knowledge  of  the  interruption. 
Usually  there  is  no  premonitory  aura  or  initial  cry.  Clonic  spasm  may 
be  barely  perceptible  or  entirely  absent.  The  child  rarely  falls  or  bites 
his  tongue,  and  the  attacks  are  frequently  described  by  parents  as 
fainting  spells, — an  obvious  misnomer,  as  by  careful  observation  they 
may  be  differentiated  from  attacks  of  syncope  by  the  rigidity,  however 
transient.  If  doubt  exist  in  regard  to  these  "spells,"  in  which  there 
is  only  slight  rigidity  and  brief  suspension  of  mental  activity,  the  fact 
of  their  recurrence  at  longer  or  shorter  intervals  would  aid  in  establish- 
ing the  diagnosis. 

Focal  or  Jacksonian  epilepsy  is  a  term  given  to  clonic  convulsive 
seizures  confined  to  a  single  muscle  or  group  of  muscles.  Consciousness 
is  maintained,  hence  it  is  not  a  true  epilepsy  according  to  the  definition. 
The  recurrent  character,  however,  is  present.  Jacksonian  epilepsy  is 
always  due  to  some  gross  lesion  in  the  motor  cortex.  The  member  first 
involved  in  the  convulsive  attack  indicates  the  area  of  the  lesion.  Partial 
epilepsy  frequently  extends  to  other  members  and  finally  develops  into 
the  major  form  of  the  disease. 

"Masked"  epilepsy  includes  a  variety  of  atypical  phenomena  which 
are  more  or  less  associated  with  the  typical  epilepsy,  although  lacking  in 
many  of  its  salient  features.  Of  this  variety  "psychic"  epilepsy  is 
interesting  as  an  explanation  of  the  recurrence  of  mental  aberration,  un- 
controllable outbursts  of  temper,  or  unusual  and  inexplicable  conduct 
on   the    part    of    children   otherwise    apparently   normal.      Observation 


EPILEPSY  399 

extending  many  years  will  show  some  of  these  cases  developing  ulti- 
mately true  epilepsy  or  even  mania. 

The  duration  of  an  epileptic  seizure  may  be  from  a  few  seconds 
to  five  minutes,  rarely  exceeding  this.  The  frequency  of  the  attacks 
may  vary  from  one  in  several  years  to  fifty  or  more  a  day,  when  one 
attack  follows  another  so  closely  that  consciousness  is  hardly  regained. 
This  grave  condition  is  known  as  status  epilepticus,  during  which  the 
temperature  rises,  cyanosis  is  extensive,  and  death  may  occur  at  any 
moment. 

In  the  early  part  of  its  history  the  attacks  may  occur  only  at  night 
(nocturnal  epilepsy)  and  pass  unnoticed,  unless  very  severe.  They  are 
sometimes  discovered  by  nocturnal  enuresis  or  tongue  wounds  which  are 
explainable  in  no  other  way.  Day  attacks  usually  succeed  later,  with 
increased  frequency  and  severity. 

Diagnosis. — The  diagnosis  of  epilepsy  is  not  made  from  the  convul- 
sion itself,  which  presents  no  distinguishing  feature  from  eclamptic 
seizures  from  a  variety  of  causes, — as  cerebral  lesions,  hemorrhages, 
meningitis,  hydrocephalus,  tumors,  and  abscesses.  In  these  there  would 
be  in  the  intervals  some  form  of  paralysis,  spasticity,  exalted  reflexes, 
rise  of  temperature,  focal  symptoms,  or  bulging  fontanelles  in  infants. 

From  uraemia  it  may  be  distinguished  by  the  absence  of  oedema  and 
fatty  and  granular  casts,  although  albumin  and  hyaline  casts  are  often 
found  the  first  hours  following  an  attack. 

The  stigmata  of  hysteria  are  less  marked  in  childhood,  and  hence  are 
of  less  aid  in  diagnosis.  The  characteristics  of  the  urine  differ  from 
those  of  epilepsy  in  that  the  solids  are  diminished  after  an  hysterical 
attack.  In  epilepsy,  on  the  contrary,  the  solids,  especially  urea  and 
phosphates,  are  increased.  Deep  unconsciousness  is  not  present,  and  the 
spasmodic  movements  of  hysteria  differ  in  that  they  represent  mere  ex- 
aggerations of  normal  movements.  The  absence  of  tongue-biting  and 
traumatisms  from  falls  or  violent  contact  with  furniture,  etc.,  would 
point  to  hysteria. 

The  ordinary  eclampsia  of  infancy  and  childhood  disappears  with 
the  removal  of  the  cause.  The  history  of  the  case,  the  absence  of  an 
aura,  and  principally  the  recurrence  of  attacks,  are  diagnostic  points. 

Prognosis. — Death  from  epilepsy  in  childhood  is  exceedingly  rare, 
although  fatal  accidents,  to  which  the  attacks  subject  their  victims,  occa- 
sionally occur.  Asphyxiation  may  result  from  a  prolonged  spasm  of  the 
respiratory  muscles.  Infancy  and  childhood  often  mark  the  beginning 
of  a  disease  whose  baleful  or  fatal  effects  wreck  adult  life. 

A  few  spontaneous  recoveries  are  on  record  which  are  credited,  in 
some  instances,  to  the  occurrence  of  some  acute  disease  or  the  changes 
incident  to  some  "period  of  stress,"  as  pubescence  or  adolescence. 

Hereditary  cases  prove  the  most  intractable,  with  the  greatest  ten- 
dency to  idiocy  and  insanity.  Degenerative  brain  lesions  also  furnish  a 
gloomy  prognosis.  Focal  varieties,  if  taken  before  the  paroxysms  become 
general,  afford  a  field  for  surgical  treatment  with  some  hope  of  relief. 


400  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  same  is  true  of  convulsions  from,  recent  traumatisms,  if  early  opera- 
tion is  undertaken. 

Treatment. — The  therapy  of  epilepsy  has  improved  in  recent  years 
by » the  abandonment  of  the  myriad  medicinal  agents  for  one  or  two  of 
known  value.  Xo  drug  has  ever  proved  a  specific,  but  the  greatest 
amount  of  amelioration,  with  an  occasional  cure,  has  followed  the 
judicious  use  of  bromides.  Whether  this  agent  acts  solely  by  obtunding 
the  irritability  of  nerve-centres,  or  transmissibility  of  nervous  impulses, 
or  restricts  the  action  of  toxins  in  the  blood  (a  property  claimed  to  be 
proven  upon  lower  animals  by  the  injection  of  bromides  and  toxins),  it 
certainly  has  been  demonstrated  that  under  its  administration  the  par- 
oxysms of  epilepsy  have  been  lessened  in  frequency  and  their  severity 
mitigated.  The  drug  should  be  administered  in  moderately  full  doses 
for  months  and  years,  with  intervals  of  remission  of  a  few  days  each 
month.  Nor  should  its  use  be  discontinued  until  several  months  after 
the  cessation  of  the  attacks.  The  tendency  of  epilepsy  to  recur  after 
months  or  even  years  should  cause  the  drug  to  be  resumed  after  any 
disturbance  of  health,  as  a  preventive.  The  combination  of  bromide  of 
potassium,  sodium,  and  ammonium,  it  is  claimed,  is  more  efficient  than 
the  single  salt.  It  should  be  given,  well  diluted  with  an  alkaline  water, 
three  times  daily,  the  night  dose  being  larger  for  the  nocturnal  form. 
If  a  regular  periodicity  of  attack  be  apparent,  an  increase  in  the  quantity 
of  bromides  should  precede  the  time  of  the  expected  seizure. 

It  is  now  believed  that  the  bromides  may  be  given  in  small  doses,  but 
with  increased  efficiency,  if  sodium  chloride  be  withheld  from  the  diet. 
The  substitution  of  the  bromide  for  the  chloride  salt  is  worthy  of  trial. 
The  well-known  tendency  of  bromides  to  cause  acne,  as  well  as  anaemia, 
may  be  counteracted  by  the  occasional  course,  for  a  few  days,  of  Fowler 's 
solution.  The  possibility  of  syphilis  in  the  etiology  warrants  the  addition 
of  potassium  iodide  to  the  daily  therapy. 

The  treatment  by  drugs  will  be  of  little  avail  if  the  hygiene  be 
neglected.  Every  possible  influence  that  may  cause  intoxication  or  excite 
reflex  irritation  must  be  removed.  The  condition  of  the  digestive  organs 
requires  particular  attention,  hence  the  correction  of  constipation  is 
indicated  to  prevent  decomposition  of  food  and  formation  of  ptomaines 
in  the  intestinal  tract.  "With  this  in  view,  nutrition  must  be  maintained 
by  foods  most  easily  digested.  Excess  of  carbohydrates,  as  well  as  too 
much  meat,  must  be  avoided.  Exercise  without  fatigue,  occupation 
without  worry  or  excitement,  with  a  free  outdoor  life,  should  be  the 
rule. 

If  an  aura  precede  the  attacks,  abortive  treatment  may  be  tried  by 
the  cautious  inhalation  of  amyl  nitrite  or  the  use  of  nitroglycerin. 

Xo  procedure  can  shorten  the  duration  of  an  attack  or  mitigate  the 
severity  after  the  spasm  has  developed.  Efforts  at  friction,  massage,  or 
reduction  of  the  contractions  are  useless.  Care  should  be  taken  to  pre- 
vent traumatism  by  bruises  and  falls.  A  cork  or  piece  of  wood  should  be 
inserted  between  the  teeth  to  prevent  biting  the  tongue. 


TETANY  401 


TETANY — TETANILLA. 

Tetany  is  a  condition  of  increased  nervous  irritability  manifested  by 
repeated  tonic  spasms.  These  convulsions  are  confined  principally  to  the. 
flexors  of  the  hands  and  feet,  but  may  involve  the  legs  and  arms,  in- 
cluding their  adductors.  In  rare  cases,  the  large  abdominal  muscles 
become  affected,  as  well  as  those  of  the  thorax,  neck,  and  pharynx. 

The  older  records  show  that  it  occurred  with  about  equal  frequency 
in  children  and  adults,  but  more  recent  reports  indicate  a  large  number 
of  cases  in  early  life. 

No  specific  cause  for  tetany  is  known,  although  it  is  generally  recog- 
nized that  conditions  of  lowered  nutrition,  especially  rhachitis,  favor  the 


Fig.  149.— Unusual  form  of  tetany.  Rhachitic  infant  of  15  months.  Tonic  spasm  lasting  five  weeks, 
with  laryngismus.  Complete  recovery  in  one  week  under  treatment  with  chloral  and  bromides.  (Dr. 
C.  A.  Wade. ) 

attacks.  Gastro-enteritis,  with  dilatation  of  the  stomach,  has  been  the 
most  frequent  precursor.  Some  form  of  intoxication  is  generally  con- 
sidered an  active  agent  in  the  causation. 

Tetany  is  most  commonly  seen  in  the  winter  and  spring  months. 
Agents  or  influences  that  cause  reflex  irritation  may  induce  the  attacks 
in  those  predisposed  to  tetany.  Thus,  pressure  or  a  blow  over  a  nerve- 
trunk  will  cause  a  characteristic  spasm  in  the  muscle  it  supplies, — as 
pressure  on  the  femoral  nerve  causing  spasm  of  the  leg  (Trousseau's 
sign),  or  light  percussion  over  the  trigeminus  below  the  zygoma  pro- 
ducing contraction  of  the  facial  muscle  (Chvostek's  sign).  The  galvanic 
or  faradic  current  reveals  hyperexcitability  of  many  groups  of  muscles 
(Erb's  sign). 

26 


402  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  picture  of  tetany  is  unique  and  is  easily  recognized.  The  condi- 
tion is  described  as  carpopedal  spasm  involving  one  or  all  four  of  the 
extremities  in  a  tonic  rigidity.  The  feet  are  in  a  position  of  pes  equinus 
or  equinovarus,  with  plantar  flexed  toes.  The  knees  may  be  slightly 
flexed  upon  the  thighs,  or  the  latter  may  be  so  strongly  adducted  that 
the  legs  cross.  The  hands  are  flexed  upon  the  forearm,  rotated  inward, 
with  occasional  flexion  at  the  elbow  and  firm  adduction  to  the  chest. 
The  fingers  and  thumbs  are  flexed  at  the  metacarpo-phalangeal  joints  in 
the  characteristic  position  known  as  the  accoucheur 's  hand.  All  the  joints 
implicated  are  rigid.  These  positions  are  maintained  with  a  degree  of 
unyielding  spasticity  for  days  and  in  extreme  cases  for  weeks.  Some- 
times there  are  tremors  in  the  affected  limbs  and  occasional  fibrillary 
twitchings  of  the  muscles  least  involved.  Pain  is  shown  by  the  whining 
cry  of  the  patient  and  is  increased  by  any  effort  at  active  or  passive 
extension. 

The  duration  of  the  disorder,  as  well  as  the  periods  between  the 
spasms,  vary  in  length.  There  may  be  an  extreme  degree  of  exhaustion 
dependent  upon  the  duration  and  intensity  of  the  spasms. 

As  a  rule  there  is  no  disturbance  of  temperature.  When  pyrexia  does 
occur  it  is  attributed  to  some  accompanying  condition,  most  frequently 
gastro-enteric  infection.  Intense  desire  with  inability  to  urinate  shows 
spasm  of  the  bladder,  while  occasionally  respiration'  is  embarrassed  by 
involvement  of  the  diaphragm  and  muscles  of  the  abdomen  and  trunk. 

Remissions  and  exacerbations  of  varying  length  may  succeed  each 
other  for  weeks  and  even  months,  with  a  probability  of  recovery  in  a 
large  majority  of  cases,  although  death  may  occur  from  pneumonia 
resulting  from  embarrassed  respiration. 

Tetany  may  be  diagnosed  from  spasms  due  to  cerebral  lesions  by 
its  tonic  character  and  absence  of  focal  symptoms ;  from  tetanus  by  its 
local  character,  being  usually  restricted  to  the  extremities,  and  the  ab- 
sence of  trismus. 

The  treatment  for  the  contractures  and  pain  may  include  dry  heat  to 
the  affected  parts,  warm  baths  long  continued,  large  doses  of  bromides, 
hyoscine  hydrobromate,  bromidia,  chloral  preferably  by  rectum,  bromo- 
form  cautiously  administered,  morphine  or  codeine  hypodermatically, 
or  even  inhalations  of  chloroform  in  extreme  cases.  Massage,  passive 
motion,  and  electricity  should  be  avoided.  The  gastro-enteritis,  if  pres- 
ent, demands  special  treatment  (lavage,  etc.),  and  the  bowels,  if  consti- 
pated, should  be  freely  opened.  As  malnutrition  is  the  chief  underlying 
cause,  the  most  important  treatment  is  that  for  rhachitis. 

LARYNGISMUS   STRIDULUS — LARYNGOSPASM  ;    CEREBRAL    CROUP. 

Laryngismus  stridulus  is  also  known  by  the  terms  asthma  rhachiti- 
cum,  internal  convulsions,  and  breath-holding  spells.  It  is  a  neurosis, 
the  manifestations  of  which  appear  in  irregular  spasmodic  action  of  some 
of  the  muscles  of  respiration.  One  of  its  most  familiar  forms  is  a  nar- 
rowing of  the  glottis  by  spasmodic  contraction  of  its  adductors,  obstruct- 


LARYNGISMI'S    STRIDULUS  403 

ing  the  free  entrance  of  air.  Abortive  and  irregular  efforts  at  inspira- 
tion, as  well  as  expiration,  show  that  some  or  many  of  these  opposed 
muscles,  and  also  the  diaphragm,  may  be  involved  in  the  irregular  spas- 
modic attack.  These  phenomena  are  so  frequently  associated  with  those 
of  carpopedal  spasm  as  to  more  than  suggest  a  common  etiology. 

The  well-known  instability  of  nervous  equilibrium  in  rhachitis  is 
apparent  as  a  predisposing  factor  in  the  spasmodic  action  of  the  muscles 
involved  in  this  disorder.  This  is  emphasized  by  statistics  which  show 
that  an  exceedingly  large  proportion  of  infants  subject  to  laryngismus 
exhibit  other  evidences  of  rhachitic  malnutrition.  When  we  consider  the 
age  of  its  most  frequent  occurrence  (from  five  to  eighteen  months)  it  is 
evident  that  in  many  of  the  younger  patients  these  attacks  antedate  the 
more  pronounced  bony  changes  of  rhachitis.  Any  occurrence  which 
disturbs  this  unstable  equilibrium  may  act  as  an  exciting  cause  of  an 
attack.  Among  the  causes  usually  mentioned  are  fright,  anger,  indi- 
gestion, cold,  or  any  trivial  disturbance,  as  suddenly  lifting  the  child, 
bathing  it,  etc. 

Exceptional  cases  are  reported  in  young  infants  and  even  in  the 
newly  born,  also  as  late  as  the  eighth  year.  Post-mortems  after  fatal 
attacks  of  laryngismus  stridulus  fail  to  show  any  anatomic  lesions 
explanatory  of  the  phenomena. 

Undoubtedly  this  disorder  is  more  common  in  Great  Britain  and 
Europe  than  in  America,  which  emphasizes  its  close  association  with 
rhachitis,  more  widely  prevalent  in  those  countries. 

The  attacks  show  no  preference  between  night  and  day  and  may 
occur  during  sleep,  from  which  the  child  is  aroused  by  their  violence. 
They  appear  more  frequently  in  the  winter  and  spring  months,  probably 
from  poorer  hygiene,  closed  rooms,  and  greater  liability  to  bronchial 
catarrhs.  As  in  other  neuroses,  the  existence  of  a  family  type  has  been 
claimed  by  some,  but  this  has  been  explained  by  others  on  the  ground 
of  routine  family  malhygiene. 

As  its  name  implies,  laryngismus  is  a  spasmodic  inspiratory  stridor, 
with  a  crowing  sound  produced  by  the  intake  of  air  as  it  rushes  through 
the  narrowed  chink  of  the  glottis.  It  may  appear  as  a  prolonged  whoop 
after  a  series  of  almost  inaudible  expiratory  sobs,  resembling  somewhat 
pertussis.  With  less  disturbance  or  conscious  recognition,  an  occasional 
short  vocalization  is  heard  upon  inspiration.  Sometimes  a  child  gives 
one  or  two  short  inspiratory  crows  when  startled,  as  when  suddenly 
aroused  from  sleep.  During  fits  of  anger  or  after  fright  or  crying,  the 
familiar  phenomenon  of  breath-holding  illustrates  one  form  of  the  dis- 
order. In  contrast  to  this  the  apncea  may  be  prolonged  to  extreme 
asphyxiation.  The  respiratory  muscles  are  temporarily  quiescent  in 
extreme  inspiration.  Sometimes  the  abdomen  heaves  spasmodically  as 
the  diaphragm  contracts,  until  sudden  relaxation  of  the  laryngeal  spasm 
allows  the  inrush  of  air.  During  the  severe  spasms  consciousness  is 
sometimes  suspended,  carpopedal  or  general  clonic  convulsions  follow. 
and  occasionally  death  occurs.     Some  of  these  symptoms  with  varying 


404  DISEASES    OF    THE    NERVOUS    SYSTEM 

grades  of  severity  may  recur  a  dozen  or  more  times  a  day,  or  only 
at  long  and  infrequent  intervals,  and  may  be  so  slight  as  to  attract 
but  little  attention.  There  is  a  tendency  to  recurrence  after  weeks 
or  months  with  lessened  frequency  towards  the  close  of  the  period  of 
dentition. 

Diagnosis. — It  is  diagnosed  from  croup  by  the  absence  of  febrile 
symptoms  and  cough,  the  unchanged  voice  or  cry,  and  in  severe  cases 
the  more  complete  although  temporary  occlusion.  The  differentiation 
will  be  difficult  or  impossible  when  catarrhal  laryngitis  and  spasm  of  the 
glottis  are  both  present.  In  neurotic  children  any  laryngeal  inflamma- 
tion may  be  complicated  by  stridor.  From  asthma  it  is  diagnosed  by  the 
absence  of  expiratory  spasm,  cough,  and  emphysema. 

Prognosis. — Fatalities  from  laryngospasm  are  less  frequently  ob- 
served in  this  country  than  in  Europe.  The  milder  forms  are  usually 
regarded  as  significant  of  a  need  for  better  nutrition.  It  should  never 
be  forgotten,  however,  that  the  severe  attacks  present  conditions  of  grave 
peril.  In  poorly  nourished,  rhachitic  infants  the  gravity  of  catarrhal 
disorders  of  the  respiratory  tract  may  be  greatly  increased  by  the 
addition  of  this  neurosis. 

Treatment. — The  treatment  should  be  directed  to  the  improvement  of 
the  underlying  condition  and  to  the  relief  of  the  acute  attack.  If  the 
symptoms  be  alarming,  relaxation  of  the  spasm  may  be  induced  by 
fanning  or  sprinkling  the  face  with  cold  water.  The  epiglottis  should 
be  raised  by  dragging  the  tongue  forward.  Cautious  inhalation  of 
ammonia  or  camphor  may  be  tried.  Bromides,  chloral,  and  belladonna 
are  all  serviceable.  Bromoform,  if  exhibited,  must  be  used  guardedly. 
Immediate  evacuation  of  the  bowel  by  a  copious  enema,  and  the  adminis- 
tration of  a  laxative,  are  always  indicated.  In  extreme  cases  intubation 
may  be  necessary,  or  a  hard  catheter  may  be  introduced  into  the  trachea 
for  temporary  relief.  Oxygen  may  then  be  used.  All  lesions  of  the 
upper  respiratory  or  genito-urinary  tract  should  be  corrected. 

THOMSEN'S   DISEASE — MYOTONIA    CONGENITA. 

Myotonia  congenita  is  characterized  by  inertia  of  the  muscles.  It 
may  be  confined  to  one  group,  as  of  the  leg,  or  all  the  extremities  may 
be  involved.  It  is  congenital,  distinctly  hereditary  and  familial,  recur- 
ring in  several  generations. 

Although  present  from  birth  in  some  degree,  it  becomes  more  marked 
at  puberty  and  continues  throughout  life.  Its  etiology  is  obscure.  It 
is  most  marked  upon  first  attempting  to  use  the  muscles,  disappears 
during  prolonged  exercise,  only  to  reappear  after  long  periods  of  rest. 
The  condition  of  the  affected  muscles  is  best  described  as  inertia  from 
the  tardy  initiative  contractibility  and  the  delay  in  relaxation.  If  the 
child  is  presented  with  a  toy  or  coin,  after  hesitation  the  hand  is  ex- 
tended with  apparent  difficulty  to  grasp  the  object,  and  the  same  diffi- 
culty appears  in  relinquishing  his  hold.  There  may  be  extreme  diffi- 
culty in  rising  from  the  sitting  posture  or  inability  to  walk  after  long 


HYSTERIA  405 

standing,  as  though  the  muscles  were  locked  in  a  tonic  spasm.  As  before 
stated,  the  disability  disappears  after  exercise. 

The  muscles  involved  are  larger  than  the  average,  although  not  pro- 
portionately strong.  Microscopical  examination  of  the  affected  muscles 
during  life  has  shown  hypertrophy  of  muscular  fibres,  a  distinct  division 
of  these  fibres  into  angular  fields,  and  proliferation  of  nuclei.  The 
motor  nerves  and  end-plates  show  no  deviation  from  the  normal.  Re- 
sponse to  mechanical  or  electrical  stimulation  is  slow ;  a  sharp  tap  over 
the  muscle  is  tardily  followed  by  an  exaggerated  wave  of  contraction 
which  sweeps  throughout  its  length.  To  both  faradic  and  galvanic  cur- 
rents the  affected  muscles  show  increased  excitability,  while  the  con- 
ductivity of  the  nerves  remains  unchanged. 

Diagnosis. — From  tetanic  contraction  and  all  other  spastic  conditions 
it  is  diagnosed  by  its  characteristic  disappearance  during  exercise  and 
reappearance  after  rest.  It  is  to  be  distinguished  from  the  physiologic 
myotonia  neonatorum  by  the  disappearance  of  the  latter  with  normal 
development.  By  the  same  transient  duration  may  be  excluded  also  the 
tonic  spasms  of  the  new-born  (paramyotonia)  which  are  caused  by  the 
sudden  change  of  temperature,  and  may  last  from  a  few  minutes  to 
several  hours. 

To  pseudohypertrophy  the  only  point  of  resemblance  is  the  increased 
bulk  of  the  affected  limb. 

No  specific  treatment  is  known.  Active  exercise  improves  the  func- 
tion of  the  muscles.  By  gradually  acquired  familiarity  with  his  idio- 
syncrasy and  self-training,  the  patient  becomes  able  to  avoid  accidents 
and  follow  some  occupations. 

HYSTERIA. 

From  whatever  point  of  view,  the  psychical  aspect  of  hysteria  is  the 
most  prominent.  Of  all  the  stigmata  of  this  protean  disorder,  mental 
impressionability  is  clearly  the  most  pronounced.  If  in  addition  to 
this  there  be  vicious  education  and  neurotic  heredity,  the  etiology  of 
hysterical  phenomena  is  complete.  The  older  idea,  still  somewhat 
prevalent,  that  hysteria  is  a  disorder  peculiar  to  women  was  a  natural 
result  of  the  exploded  dogma  that  its  cause  lay  in  diseases  of  the 
uterus.  That  hysterical  manifestations  and  stigmata  were  so  long  un- 
recognized in  childhood  may  further  be  accounted  for  by  the  lack  of 
application  of  definite  methods  of  diagnosis  to  disorders  of  this  pe- 
riod. From  the  present  knowledge  of  hysteria,  children  are  as  prone 
to  this  disease  as  their  elders.  The  non-recognition  of  this  is  probably 
due  to  the  fact  that  childhood  does  not  present  as  many  varieties  of 
stigmata  in  the  same  individual  as  frequently  may  be  seen  in  older  cases. 
Time,  however,  develops  some  of  these  obscure  cases  into  the  commonly 
recognized  mature  type,  with  wealth  of  phenomena  sufficient  to  satisfy 
the  most  incredulous. 

Since  there  is  no  anatomical  lesion  in  hysteria  its  causation  must  be 
due  to  functional  disturbances  of  the  nervous  system. 


406  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  dramatic  paroxysmal  attacks  which  receive  so  much  attention 
are  of  less  importance  than  the  interparoxysmal  and  underlying  condi- 
tions that  allow  the  explosions.  The  acute  manifestations  may  be  in- 
duced by  any  physical  or  mental  shock  or  excitement,  acting  upon  an 
unstable  nervous  organization,  feebly  presided  over  by  an  uneducated 
will.  Children  whose  immediate  or  remote  ancestry  show  hysteria,  in- 
sanity, epilepsy,  alcoholism,  and  possibly  gout  and  tuberculosis,  exhibit 
a  predisposition  to  hysteria  which  may  be  augmented  by  the  effects  of 
recent  sickness,  school-strain,  physical  fatigue,  or  even  imitation.  If  the 
life  and  education  of  such  children  be  not  such  as  to  develop  an  unusual 
degree  of  self-control,  the  question  of  acute  hysterical  phenomena  de- 
pends entirely  upon  the  presence  or  absence  of  an  exciting  cause,  in 
itself  insignificant. 

Fits  of  screaming  or  immoderate  laughter  may  represent  the  lightest 
manifestations  of  a  hysterical  tendency.  Between  these  and  the  major 
attacks  every  degree  of  hysteria  may  be  seen  in  childhood. 

The  picture  of  the  grand  attack  in  children  differs  from  that  in 
adults  principally  in  the  demonstrations  of  the  dramatic  stage,  which 
are  restricted  in  accordance  with  the  limited  knowledge  and  observa- 
tions of  the  patient ;  thus  some  of  the  heroic  emotional  attitudes  may  be 
wanting.  The  convulsions  and  delirium  may  represent  every  phase  of 
its  adult  type.  The  motor  symptoms,  both  paretic  and  spastic,  are  seen 
in  all  forms  and  degrees.  Paraplegia  occurs  more  frequently  than  in 
the  adult,  and  a  monoplegia  or  hemiplegia  may  be  the  only  pronounced 
or  initial  symptom  of  the  disorder.  The  sudden  onset,  sometimes  the 
unexpected  transference  to  other  groups  of  muscles  or  abrupt  dis- 
appearance, are  in  marked  contrast  to  the  plegias  of  organic  origin. 
Tremors  are  not  as  frequent  as  in  older  life.  The  hysteric  joints  may 
closely  simulate  genuine  arthritic  or  bone  lesions,  as  tuberculosis  of  the 
hip  and  vertebra?,  and  have  been  mistakenly  treated  as  such. 

Laryngeal  paresis  with  aphonia  is  a  very  common  symptom  in  young 
children,  especially  following  fright.  Vesical  spasm  causing  retention 
of  urine  is  usually  transient.  Persistent  singultus  is  frequently  observed. 
From  involvement  of  the  intestinal  tract  there  may  follow  diarrhoea,  or 
meteorism  to  enormous  abdominal  distention.  Occasionally  vomiting 
occurs  and  proves  obstinate  to  control  from  apparent  perversity. 

Torticollis  is  sometimes  seen,  and  deformities  such  as  spinal  curvature 
from  tonic  contractures  of  the  great  muscles  of  the  trunk,  may  persist 
for  weeks.  The  tissues  about  the  flexed  joints  may  swell  and  the  muscle 
contractures  from  long-continued  malposition  and  disuse  add  to  the  de- 
formities.   The  involved  areas  may  show  exquisite  tenderness  to  the  touch. 

All  the  various  disturbances  of  sensation,  as  anaesthesia,  hyperaes- 
thesia,  paresthesia,  analgesia,  and  hypalgesia,  present  all  the  vagaries 
seen  in  the  adult.  Tender  points  along  the  spine,  over  the  cranium  and 
trunk  are  common.  The  cranial  tenderness  may  or  may  not  be  associated 
with  headache  of  the  typical  boring  character  (clavus).  Hysterogenic 
areas  may  be  found,  but  diminished  sensation  to  touch  and  pain  is  less 


HYSTERIA  407 

common.  Hemianesthesia  is  occasionally  seen.  Faucial  and  laryngeal 
hyperesthesia  with  resultant  cough  is  a  more  frequent  symptom. 

Disturbances  of  the  special  senses  are  common  and  may  be  the  only 
symptoms  present,  as  deafness  in  one  or  both  ears,  perversion  or  loss  of 
taste  or  smell,  or  there  may  be  blindness  (uni-  or  bilateral)  for  which  the 
oculist  can  find  no  cause.  As  in  adults  the  visual  field  may  be  restricted, 
laterally  or  concentrically,  but  this  is  a  symptom  difficult  to  bring  out 
in  the  young  child.  No  attempt  is  here  made  to  go  over  the  entire  field 
of  psychomotor-sensory  disturbances.  A  few  only  are  mentioned  which 
are  more  characteristic  of  this  disorder  in  childhood. 

Diagnosis. — The  possibility  of  the  engraftment  of  hysterical  symp- 
toms upon  any  pathological  condition  must  never  be  lost  sight  of  in 
treating  children  of  a  neurotic  tendency.  Frequently  the  refinements  of 
diagnosis  are  necessary  to  differentiate  between  the  organic  symptoms 
and  those  of  hysteria.  Previous  acquaintance  with  the  child's  history, 
or  with  the  action  of  remedial  agents,  frequently  aid  the  physician  in 
the  elision  of  neurotic  features. 

From  epileptic  seizures,  hysterical  fits  should  be  diagnosed  by  the 
emotional  symptoms  preceding:  the  absence  of  aura,  tongue-biting,  or 
other  self-inflicted  injuries,  of  spasmodic  evacuation  of  bladder  and 
rectum,  and  rarely  of  complete  unconsciousness.  The  movements  of  hys- 
teria are  more  purposeful,  less  jactitating  in  character,  and  wider  in  the 
amplitude  of  their  range. 

The  differentiation  is  not  always  easy,  as  is  evident  by  the  term  hys- 
tero-epilepsy, — a  misnomer,  as  an  epileptic  attack  needs  no  adjective. 
The  possibility  of  alternation  of  the  two  kinds  of  convulsions  in  the 
same  child  must  be  remembered. 

The  relation  between  chorea  and  hysteroid  manifestations  is  interest- 
ing in  so  much  as  both  are  imitative  in  character  and  develop  in  nervous 
children  under  similar  conditions. 

From  true  plegias,  hysteria  should  be  distinguished  by  the  absence  of 
all  evidence  of  changes  due  to  anatomical  lesions  in  the  central  nervous 
system,  excepting  the  moderate  atrophy  from  disuse. 

From  all  the  simulated  diseases  of  nervous,  muscular,  or  visceral 
origin,  the  absence  of  evidence  of  structural  changes  and  the  presence 
of  some  of  the  stigmata  of  hysteria  should  clear  up  the  diagnosis. 

Prognosis. — Hysteria  is  never  reported  as  a  cause  of  death,  although 
hysterical  delirium  may  lead  to  delusions,  melancholia,  mania,  and 
suicide. 

Treatment. — The  evolution  from  the  hysterical  diathesis  is  probably 
purely  educational.  Improvement  in  physical  health  and  in  environ- 
mental conditions,  with  developing  inhibition,  may  do  much  for  the 
relief  of  the  hysterical.  The  study  of  the  individual,  with  the  appli- 
cation of  the  best  known  principles  of  hygiene,  physical,  mental,  and 
moral,  a  change  of  control  from  that  of  an  emotional  parent  to  a  person 
of  perfect  equipoise,  of  gentle  nature,  and  firm  discipline,  may  at  this 
early  period  of  life  do  much  to  overcome  the  morbid  inheritance. 


408  DISEASES    OF    THE    NERVOUS    SYSTEM 


CATALEPSY. 

This  condition,  closely  associated  with  hysteria,  epilepsy,  melancholia, 
and  developing  insanity,  is  extremely  rare  in  infancy  and  seldom  seen 
in  childhood. 

The  state  is  characterized,  as  in  the  adult,  by  more  or  less  loss  of 
consciousness,  moroseness,  irritability,  and  other  hysterical  manifesta- 
tions, but  more  particularly  by  the  well-known  lead-pipe  spasticity  of 
the  limbs,  which  retain  for  a  long  time  whatever  position  they  are  made 
to  assume. 

The  etiology  is  obscure.  It  has  been  known  to  take  the  place  of  the 
chill  in  malaria,  to  follow  fright,  intense  emotional  disturbance,  or  high 
temperature  in  febrile  disorders.  It  appears  as  a  psychomotor  neurosis, 
engrafted  on  or  induced  by  other  diseased  conditions.  In  many  cases 
it  has  an  erotic  complexion  and  has  been  manifest  in  children  addicted 
to  masturbation. 

The  treatment  is  primarily  that  of  the  underlying  disorder.  For 
the  cataleptic  attacks  cautious  inhalation  of  ammonia,  mixed  bromides 
in  full  doses,  and  cool  sponging,  are  worthy  of  trial.  Quinine  is  indi- 
cated in  malaria.  Circumcision  or  attention  to  genital  irritation,  thor- 
ough oversight  of  moral  and  mental  hygiene,  change  of  environment  and 
associates,  may  all  be  instituted  with  a  view  to  intercepting  the  morbid 
suggestions  before  the  cataleptic  spasms  become  habitual.  The  careful 
management  of  the  child  through  pubescence  may  rescue  him  from  the 
evil  sequels  of  this  malady. 

CHOREA. 

The  chorea  of  Sydenham  is  generally  regarded  as  a  functional  affec- 
tion, unattended  by  any  demonstrable  lesion.  It  is  characterized  by  a 
series  of  exaggerated  normal  or  purposeless  movements  of  voluntary 
muscles,  without  loss  of  consciousness,  and  associated  usually  with  con- 
siderable emotional  irritability.  The  movements  may  involve  any  or  all 
of  the  voluntary  muscles.  They  may  appear  in  one  member  only  or 
involve  one  side  of  the  body, — hemichorea.  They  may  range  in  severity 
from  barely  perceptible  twitchings  of  a  limited  group  to  widely  gro- 
tesque, aimless  muscular  movements  of  face,  head,  trunk,  and  extremities. 
In  cases  of  average  severity  the  temporary  control  of  the  movements  by 
exercise  of  the  child's  will  is  always  followed  immediately  by  increase 
in  the  muscular  incoherency. 

It  occurs  most  commonly  between  the  ages  of  five  and  fifteen  years 
and  three  times  as  frequently  in  girls  as  in  boys.  It  may  be  seen  in 
younger  children,  and  congenital  cases  have  been  reported.  By  far  the 
large  proportion,  probably  one-half,  develop  during  the  spring  months, 
so  that  at  this  time  recurrences  are  apprehended  by  parents.  Many 
cases  show  a  marked  neurotic  heredity,  and  a  direct  history  of  chorea  in 
mother  or  older  sisters  is  obtained. 

Chorea  is  so  frequently  associated  with  rheumatism  that  it  has  come 


CHOREA  409 

to  be  regarded  as  one  of  the  manifestations  of  that  diathesis.  Even  if 
this  association  be  limited  to  those  cases  showing  acute  rheumatic  arthri- 
tis, a  rather  rare  form  in  early  childhood,  the  proportion  is  still  too  large 
to  be  considered  a  mere  coincidence.  While  if  the  common  symptoms  of 
rheumatism  be  considered,  as  tonsillitis,  endocarditis,  myalgia,  and 
"  growing  pains,"  this  association  becomes  convincing.  Furthermore, 
continued  observation  of  cases  of  chorea  shows,  sooner  or  later,  subse- 
quent development  of  other  rheumatic  symptoms.  The  urinary  findings 
in  uncomplicated  chorea  correspond  to  those  of  rheumatism  in  the  in- 
creased percentage  of  urates  and  uric  acid.  The  mode  of  onset,  the  self- 
limited  character  of  the  attacks,  the  accompanying  anaemia,  the  subse- 
quent heart  lesions  and  its  tendency  to  recurrence,  all  stamp  the  chorea 


Fig.  150.— Chorea  minor. 

of  childhood  as  a  phase  of  rheumatism,  with  more  than  a  suggestion  of 
microbic  etiology. 

The  fact  that  choreic  movements  occasionally  follow  certain  definite 
lesions  of  the  motor  tract  and  obvious  reflex  irritation,  has  given  rise  to 
classification,  such  as  Huntington's  chorea,  electric  chorea,  habit  spasm, 
tic  convulsif,  etc.,  but  these  should  not  be  confounded  with  the  chorea 
minor  of  childhood.  Huntington 's  chorea  is  an  hereditary  disease  which 
rarely  develops  until  after  puberty. 

Chorea  minor  is  seen  most  frequently  in  poorly  nourished  children 
of  bad  hygienic  surroundings,  or  in  those  who  have  been  subject  to 
excitement,  worry,  overstrain  from  study,  or  whose  vitality  has  been 
reduced  by  acute  sickness.  Cold  and  emotional  disturbances,  particu- 
larly fright,  are  often  given  as  exciting  causes. 

The  attack  may  develop  insidiously,  the  first  symptom  often  being  an 


410  DISEASES    OF    THE    NERVOUS    SYSTEM 

unusual  irritability.  The  child  is  peevish  and  fretful,  weeps  at  the  least 
reproof,  or  it  may  stumble  in  walking,  drop  objects,  and  show  awkward- 
ness in  all  accustomed  motions.  The  child  is  restless  and  fidgety,  espe- 
cially when  fatigued  or  embarrassed.  Incoordinate  movements  may  be 
first  observed  at  the  table  in  the  uncertain  attempts  at  feeding.  This 
incoordination  is  usually  more  pronounced  and  earliest  developed  in  the 
upper  extremities.  Gradually  other  groups  of  muscles  share  in  the 
irregular  movements  until  the  child  is  unable  to  feed  himself  or  perform 
any  of  the  habitual  duties  of  daily  life.  Speech  is  affected,  words  being 
indistinctly  enunciated  or  explosively  uttered.  A  symptom  peculiar  to 
chorea  is  the  appearance  of  the  tongue,  which,  upon  request,  is  pro- 
truded with  lightning  rapidity  from  the  widely  opened  mouth,  while  its 
dorsal  surface  undulates  with  wave-like  movements.  After  going 
through  unusual  gyratory  motions  it  may  be  jerked  back  as  suddenly 
as  it  was  protruded. 

Some  of  the  affected  muscles  show  weakness  amounting  at  times 
almost  to  a  paresis.  Loss  of  sleep,  the  constant  movements,  occasionally 
so  violent  as  to  throw  the  child  from  the  bed,  and  inanition  from  inter- 
ference with  feeding,  may  account  for  the  angemia  and  general  weakness 
which  rapidly  develop  in  severe  cases.  The  movements  usually  disap- 
pear during  sleep,  which  is  secured  only  for  short  periods. 

No  constant  change  is  seen  in  the  deeper  reflexes.  The  same  is  also 
true  of  the  temperature  in  uncomplicated  cases.  The  pulse  shows 
great  variation,  suddenly  accelerating  without  apparent  cause,  the 
heart  sharing  in  the  general  muscular  insanity.  Atony  of  the  heart 
muscle  is  seen  in  the  frequent  dilatation.  Haemic  murmurs,  both  basic 
and  apical,  are  rarely  absent  in  advanced  cases,  and  endocarditis  may 
occur. 

Diagnosis. — Although  probably  only  a  secondary  symptom  of  some 
condition  as  yet  unknown,  the  so-called  idiopathic  chorea  is  unmistakable 
in  diagnosis.  The  duration  may  be  from  a  few  weeks  to  many  months, 
many  clinical  histories  showing  an  average  of  eight  to  nine  weeks.  The 
tendency  to  recurrence  is  marked,  under  conditions  favorable  for  its 
development,  for  several  years. 

Prognosis. — The  prognosis  is  hopeful  as  far  as  life  is  concerned, 
although  death  from  inanition  or  exhaustion  may  very  rarely  occur.  A 
fatal  termination  from  the  cardiac  inflammation  must  not  be  lost  sight 
of.  A  not  uncommon  sequel  is  valvular  lesion  or  dilatation  from  the 
muscular  atony. 

Treatment. — The  treatment  consists  in  protecting  the  child  from  all 
influences  that  will  excite  or  irritate,  avoiding  all  reference  to  his  in- 
firmity. He  should  be  taken  out  of  school  and  relieved  of  all  tiresome 
duties  and  responsibilities.  The  question  of  keeping  him  constantly  in 
bed  depends  upon  the  condition  of  the  child  and  his  environment.  Close 
attention  should  be  given  to  the  digestive  organs.  Constipation  must  be 
relieved  and  elimination  promoted.  The  heart  must  be  daily  watched 
for  early  indications  of  endocarditis.    Rest  is  imperative  and  sleep  must 


HABIT    SPASM  411 

be  secured  by  adequate  means,  best  by  warm  baths  and  gentle  massage. 
In  severe  eases  sedatives  may  be  necessary.  For  this,  full  doses  of  the 
mixed  bromides  are  useful,  to  which  may  be  added  chloral  hydrate. 
When  the  continued  violent  jactitations  prevent  sleep  and  threaten  ex- 
haustion, morphine,  hypodermically,  may  be  indicated  or  even  chloro- 
form by  inhalation.  If  the  stomach  is  irritable  rectal  medication  may 
be  employed.  Sometimes  it  is  wise  to  restrict  the  tired  limbs  in  their 
erratic  movements  by  well-padded  splints.  Non-exciting  amusements 
to  divert  the  child's  mind  should  be  provided. 

The  diet  must  be  nutritious  and  non-bulky  because  of  the  diffi- 
culty in  feeding.  It  may  be  necessary  to  give  fluids  from  a  feeder 
ending  in  a  rubber  tube,  on  account  of  the  unexpected  contractions 
of  the  masseters. 

Disturbance  of  pulse-rate,  rise  of  temperature,  cardiac  souffle  or  fric- 
tion sounds  indicative  of  inflammatory  involvement  of  the  heart,  require 
appropriate  treatment. 

It  is  doubtful  if  any  specific  medication  is  available  in  this  disorder. 
Arsenic  holds  the  front  rank  among  the  scores  of  remedies  that  have 
been  employed.  It  should  be  given  well  diluted,  in  the  form  of  Fowler's 
or  Pearson's  solution,  three  times  a  day,  by  the  increasing  plan.  Gas- 
tric irritation  from  the  extravagant  use  of  this  drug  defeats  its  thera- 
peutic intention.  In  cases  of  absolute  gastric  intolerance  Pearson's  solu- 
tion may  be  administered  hypodermatically  in  five-  to  ten-minim  doses 
(0.3-0.6  C.c.) .  For  the  anaemia,  in  the  absence  of  fever,  iron  is  indicated, 
Bland's  mass  and  Basham's  mixture  being  valuable  preparations.  Cod- 
liver  oil,  either  plain  or  combined  with  hypophosphites,  should  be  given 
in  moderate  doses. 

From  the  beneficial  effects  of  salicylates  in  acute  rheumatism  these 
agents  are  worthy  of  a  trial  in  early  choreic  attacks.  Gratifying  results, 
in  shortening  their  duration,  have  been  reported  from  the  use  of  salicyl- 
ate of  sodium  or  strontium.  This  treatment  is  advisable  in  cases  where 
the  rheumatic  stamp  is  especially  marked. 

The  cacodylate  of  sodium  is  advocated  at  the  present  time  by  several 
who  claim  excellent  results  from  its  use. 

HABIT  SPASM — TIC   CONVULSIF  ;     HABIT   CHOREA;    FACIAL   TIC. 

These  forms  of  local  spasm  are  of  special  interest  in  childhood,  for 
at  that  period  the  only  opportunity  is  afforded  to  overcome  a  disorder 
which  may  prove  to  be  not  only  an  annoyance  but  a  great  inconvenience 
in  later  life.  There  is  a  great  variety  of  these  habit  spasms  or  tics,  many 
of  which  are  originally  due  to  local  lesions  in  or  adjacent  to  the  affected 
muscles,  such  as  grimacing  as  the  result  of  nasal  catarrh,  blepharospasm 
from  ocular  defects  or  palpebral  lesions.  Ill-fitting  garments  or  irrita- 
tion about  the  neck  may  be  the  cause  of  shoulder-shrugging  or  neck- 
twisting.  And  so  throughout  the  muscles  of  the  face,  trunk,  and  ex- 
tremities, movements  of  a  purposive  nature,  primarily  induced  by  some 
local  discomfort,  become  a  habit  from  frequent  repetitions.     Imitation, 


412  DISEASES    OF    THE    NERVOUS    SYSTEM 

also,  enters  largely  into  the  etiology  of  habit  spasm.  This  is  frequently 
seen  in  tricks  of  speech,  meaningless  vocal  utterances,  or  gestures  accom- 
panying certain  words  or  phrases. 

The  pathological  significance,  in  the  majority  of  these  cases,  is  unim- 
portant; but  for  the  child's  future  welfare  all  these  irregularities  of 
speech  should  be  corrected  before  the  habits  have  become  permanently 
fixed.  This  may  be  done  by  the  exercise  of  thoughtful  tact  and  patience 
on  the  part  of  the  parents,  after  the  removal  of  all  reflex  irritations. 
Training  the  muscles  in  regular  rhythmic  movements  under  the  control 
of  the  will,  as  in  calisthenics,  is  especially  to  be  recommended. 

IMPERATIVE    MOVEMENTS. 

Imperative  movements  are  subjects  of  psychical  interest  since  they 
are  seen,  in  the  most  marked  degree,  in  idiots.  In  minor  forms  they  are 
very  commonly  observed,  irrespective  of  impaired  mentality,  in  children 
as  well  as  in  adults.  Probably  every  individual  who  analyzes  his  habitual 
daily  routine  will  recognize  some  movements  which  have  no  meaning  or 
significance  other  than  the  result  of  an  habitual  impulse, — such  as  the 
purposeless  counting  of  objects  or  patterns  which  appear  in  series,  the 
stepping  on  certain  stones  in  the  daily  walk,  etc.  Between  the  two  ex- 
tremes may  lie  an  intermediate  class  of  individuals  in  whom  imperative 
conceptions  may  be  the  only  explanation  for  some  outre  demonstration 
or  criminal  act.  The  importance  of  securing  absolute  control  of  volition 
in  early  life  is  apparent  in  this  connection. 

SPASMUS   NUTANS,    HEAD-NODDING,    NYSTAGMUS. 

Spasmus  nutans  and  nystagmus  are  repeated  nodding,  rotating,  or 
oscillating  movements  of  the  head  and  eyes,  frequently  associated  but 
occasionally  seen  separately.  The  movements  may  be  horizontal,  lateral, 
or  rotary,  or  the  whole  body  may  oscillate  or  bow  rhythmically  as  in 
salaam.     The  nystagmus  may  affect  one  or  both  eyes. 

The  age  of  most  frequent  occurrence  in  childhood  is  from  the  sixth  to 
the  eighteenth  month,  although  both  affections  are  seen  at  all  ages.  The 
oscillations  of  the  eye  may  vary  in  frequency  from  fifteen  to  three  hun- 
dred to  the  minute,  and  may  be  intensified  by  fixing  the  child's  attention 
upon  some  bright  object,  or  by  holding  the  head  still. 

Occasionally  one  or  both  of  these  spasms,  beginning  in  infancy,  may 
continue  throughout  life.  As  a  rule  they  last  but  a  few  weeks  or  months, 
disappearing  gradually.  Both  are  also  seen  as  terminal  symptoms  in 
cerebral  disease. 

Their  etiology  has  been  a  subject  of  much  discussion.  As  the  move- 
ments involve  muscles  of  volition  which  are  among  the  first  to  develop 
purposive  function,  it  would  appear  that  prior  to  the  development  of 
inhibition,  early  volitional  movements  may  readily  degenerate  into  habit- 
ual movements.  A  careful  study  of  the  environments  of  these  purely 
functional  cases  usually  brings  out  some  circumstances,  as  the  habitual 
position  of  the  child  relative  to  the  light  or  to  the  visual  range  of  some 


ATHETOSIS  41:5 

bright  or  attractive  object,  as  the  origin  of  these  purposive  lateral  or 
vertical  movements  of  eyes  and  head.  Meningitis,  cerebral  tumor, 
atrophy,  sclerosis,  and  encephalitis  are  lesions  of  which  these  phenomena 
may  be  either  early  or  terminal  symptoms. 

The  prognosis,  therefore,  must  be  guarded,  recalling  the  extremes  of 
etiology.  In  a  considerable  proportion  of  cases,  rickets  and  malnutrition 
have  been  observed.  Ocular  defects  should  be  sought  for.  The  nystag- 
mus of  albinism  is  well  known.  The  movements  may  be  interrupted  in 
quiescent  periods  and  cease  entirely  during  sleep. 

The  treatment  is  that  of  the  underlying  cerebral  affection,  if  such 
exist,  or  the  improvement  of  nutrition  in  rhachitis  and  marasmus,  the 
removal  of  all  causes  of  reflex  irritation,  and  change  of  the  child's  envi- 
ronment with  reference  to  light  and  objects  to  which  his  attention  has 
been  especially  directed. 

ATHETOSIS. 

First  described  as  a  disease,  athetosis  can  hardly  be  considered  more 
than  a  symptom.     The  term  is  applied  to  slow,  rhythmic,  incoordinate 


Fig.  150.— Hemiplegic  athetosis.     (Dr.  G.  W.  Hall.) 

movements  of  different  members,  especially  the  fingers  and  toes,  although 
it  may  involve  the  limbs,  trunk,  and  head.  They  may  continue  during 
sleep.  These  movements  are  described  as  gliding  or  peristaltic,  and,  when 
the  trunk  is  involved,  as  squirming  or  writhing. 

Athetoid  movements  are  so  commonly  seen  in  very  young  infants 
that  it  is  a  question  if  they  are  of  any  pathologic  import  at  this  age.  As 
in  tetany  the  muscles  most  involved  are  the  interossei  and  lumbricales, 
with  this  difference,  that  the  contractions  are  slowly  clonic,  irregular, 
and  grotesque.    Although  apparently  non-pathologic  in  new-born  infants 


414  DISEASES    OF    THE    NERVOUS    SYSTEM 

(Fig.  5),  cases  are  reported  in  which  athetosis  persisted  for  years,  ren- 
dering the  patient  helpless.  It  may  be  unilateral  or  appear  in  the  fingers 
of  one  side  and  toes  of  the  other.  It  is  a  frequent  synrptoni  of  post- 
hemiplegia,  appearing  on  the  paralyzed  side  after  the  partial  restoration 
of  motion.  Athetoid  movements  should  always  lead  to  an  inquiry  for  the 
history  of  a  previous  palsy. 

The  muscles  involved  in  the  movements  show  hypertrophy.  When 
confined  to  the  fingers  and  toes,  the  larger  muscles  of  the  corresponding 
forearm  and  calf  show  slight  rigidity. 

Causative  lesions  have  been  found  in  some  cases  in  the  corpus  striatum 
and  optic  thalamus. 

Occasionally  the  athetoid  movements  may  be  almost  choreic  in  their 
rapidity,  or  the  two  forms  may  be  associated  in  the  same  child. 

In  athetosis  due  to  an  anatomical  lesion  there  is  little  hope  of  cure, 
although  exercise,  occupation,  and  efforts  of  the  will  may  modify  the 
movements.    No  treatment  by  drugs  has  been  of  benefit. 

PAVOR   NOCTURNTJS — NIGHT    TERRORS. 

Pavor  nocturnus  is  a  form  of  disturbed  sleep  usually  occurring  during 
the  first  hours  of  the  night.  The  child  suddenly  screams  loudly  and  is 
found  sitting  up  in  bed,  staring  with  dilated  pupils,  and  begging  to  be 
protected  from  some  imaginary  object,  as  an  animal  or  hobgoblin,  rarely 
of  known  persons.  He  fails  to  recognize  familiar  faces  for  several  min- 
utes and  is  then  quieted  with  difficulty  and  may  finally  sob  himself  to 
sleep.  The  nature  of  the  attack  may  vary,  sometimes  assuming  the  form 
of  a  dream  or  nightmare  from  which  the  child  awakes  in  terror  at  finding 
himself  alone.  He  may  relate  his  dream,  take  a  drink  of  water,  and  go 
quickly  to  sleep  again.  The  attacks  may  recur  frequently,  but  rarely 
twice  in  the  same  night. 

Among  many  varieties  two  types  are  presented.  One,  the  high-strung 
child,  overworked  at  school,  with  imagination  stimulated  by  injudicious 
reading  or  story-telling,  anaemic,  and  poorly  nourished  from  insufficient 
or  improper  food,  malhygiene,  or  previous  sickness.  His  nervous  system  is 
in  a  state  of  unstable  equilibrium  in  which  imagination  is  overdeveloped. 
Children  of  this  type  most  frequently  "  see  things"  at  night,  and  occa- 
sionally have  hallucinations  in  the  day  (pavor  diurnus). 

The  other  class  may  be  unimaginative,  apparently  well  nourished 
children,  whose  sleep  is  disturbed  by  interference  with  respiration  from 
enlarged  tonsils  or  adenoid  growths,  or  from  reflex  irritation  from  an 
overfull  stomach,  undigested  food,  or  intestinal  parasites.  These  acting 
through  the  pneumogastric  may  influence  respiration  and  cause  partial 
asphyxiation,  from  which  the  child  awakes  in  fright. 

Prognosis. — Although  the  prognosis  is  good  in  a  large  majority 
of  cases,  as  they  usually  outgrow  the  tendency  in  later  childhood, 
the  fact  must  not  be  overlooked  that  epilepsy  occasionally  follows 
night  terrors,  the  pavor  apparently  assuming  the  place  of  the  epileptic 
seizure. 


SPEECH    DEFECTS  415 

Treatment. — The  treatment  is  indicated  by  the  apparent  exciting 
causes  and  predisposition.  The  neurotic  child  should  be  relieved  from 
overwork,  so  common  in  our  schools.  If  necessary  the  child  should  be  re- 
moved from  school,  music-  and  dancing-lessons  should  be  curtailed,  com- 
pany restricted,  and  late  hours  prohibited.  The  imagination  must  be 
trained  by  less  sensational  reading,  and  interest  developed  in  outdoor 
occupations  and  amusements.  Protection  from  errors  of  diet,  as  to 
quantity,  quality,  and  time  of  feeding,  are  important.  The  relief  of  all 
conditions  which  cause  reflex  irritation  should  be  instituted.  Nor  should 
the  mental  and  moral  hygiene  of  the  child  be  overlooked.  None  but  the 
sympathetic  mother  can  appreciate  the  tender  consciences  of  these  little 
ones  to  whom  night  brings  the  retrospect  of  the  day's  naughtiness.  Going 
to  bed  should  be  relieved  of  all  idea  of  isolation.  A  door  ajar,  a  light  in  an 
adjoining  room,  serves  to  steady  the  shrinking  consciousness  of  many  a 
child  from  the  terrors  of  the  night.  A  good  physic,  a  warm  bath  before 
retiring,  a  well-ventilated  room,  with  good  digestion  of  a  plain  supper, 
will  usually  secure  sleep  free  from  pavor,  without  the  administration 
of  bromide  or  chloral,  which  should  be  given  only  in  extreme  cases. 

SPEECH   DEFECTS. 

Defects  in  speech  are  very  common  in  childhood  and  may  vary  in 
degree  from  complete  alalia  to  the  merest  lisping.  If  the  child  show 
total  absence  of  speech  at  two  years  the  parents  usually  consult  the 
physician.  A  prognosis  as  to  the  permanency  of  alalia  at  this  early 
age  is  sometimes  difficult  and  should  be  made  only  after  the  exclusion  of 
all  possible  conditions  known  to  interfere  with  the  normal  development 
of  speech.  If  the  child  has  never  spoken,  the  question  of  his  intelligence 
should  be  first  considered,  since  alalia  is  a  common  accompaniment  of 
idiocy,  and  even  minor  defects  of  speech  are  held  by  some  authorities  to 
indicate  slight  mental  impairment.  Careful  scrutiny  and  ordinary  tests 
as  to  the  degree  of  interest  and  attention  displayed  by  the  child,  together 
with  his  physical  condition  and  history  of  birth  and  development,  will 
aid  the  physician  in  his  decision.  The  question  of  hearing  should  be  set- 
tled at  once,  as  total  deafness  in  infancy,  either  congenital  or  acquired, 
always  results  in  mutism.  Examination  for  defects  in  the  organs  of 
speech,  or  for  the  presence  of  adenoids,  should  be  made.  The  environment 
of  the  child  has  much  to  do  with  his  learning  to  talk.  If  associated  with 
other  children  or  instructed  by  attentive  parents,  speech  will  develop 
earlier  than  in  children  who  are  left  to  amuse  themselves  or  are  much  in 
the  care  of  a  reticent  nurse.  Occasionally  a  child  may  not  talk  until  the 
age  of  four  years,  and  in  rare  cases  children  have  reached  the  age  of  six 
before  attaining  speech.  Usually  the  retarded  development  is  compen- 
sated by  the  rapid  acquirement  of  a  vocabulary  average  for  age. 

Tongue-tie,  commonly  supposed  to  interfere  with  speech,  probably 
does  so  only  to  the  extent  of  lisping,  a  defect  in  which  the  short  frenum 
changes  the  sibilant  s  to  th,  from  inability  to  approximate  the  tip  of  the 
tongue  to  the  roof  of  the  mouth.     Even  section  of  the  frenum,  however, 


416  DISEASES    OF    THE    NERVOUS    SYSTEM 

does  not  immediately  correct  this  defect,  as  the  habit  must  be  overcome 
by  persistent  efforts  at  correct  pronunciation. 

A  distinction  between  stammering  and  stuttering,  terms  formerly 
synonymous,  is  now  made.  Stammering  is  employed  to  designate  habit- 
ual erroneous  utterance  of  certain  sounds,  usually  due  primarily  to  some 
defect  in  the  speech  organs  or  of  their  innervation.  In  children  it  may 
be  due,  also,  to  habits  resultant  from  careless  and  uncorrected  articula- 
tion. Such  habits  of  speech  are  seen  in  racial  peculiarities  of  dialect.  A 
good  illustration  is  seen  in  the  faulty  enunciation  of  an  acquired  lan- 
guage, so  that  one  may  be  said  to  stammer  in  the  imperfect  utterance  of 
all  languages  save  his  own. 

Stuttering  may  assume  a  variety  of  forms,  the  most  common  of  which 
is  hesitation  with  a  more  or  less  prolonged  or  repeated  effort  before  the 
utterance  of  certain  syllables  usually  beginning  with  explosive  conso- 
nants. Occasionally  the  same  hesitancy  is  seen  in  the  Unguals  and  even 
vowel  sounds.  The  abortive  effort  to  enunciate  may  appear  distressing, 
the  face  is  congested,  the  muscles,  especially  of  the  throat,  chest,  and 
vocal  organs,  are  in  tetanic  spasm  until  suddenly  the  tension  termi- 
nates in  an  explosive  utterance,  followed  often  by  several  words  in  rapid 
succession. 

Of  the  many  causes,  probably  the  most  common  is  defective  co- 
ordination of  the  vocal  and  respiratory  apparatus,  and  it  is  usually 
aggravated  by  excitement  or  fatigue.  Children  also  stutter  from  imita- 
tion. The  habit  is  most  readily  acquired  before  the  forms  of  speech  are 
fully  established,  and  the  child's  ideas  run  ahead  of  his  ability  of  expres- 
sion. Faulty  methods  of  breathing  undoubtedly  favor  the  formation  of 
the  stuttering  habit. 

The  treatment  of  these  defects  requires  first  the  removal  of  any 
known  cause  and  the  teaching  of  correct  breathing.  Excitement  and 
undue  haste  should  be  repressed  and  the  child  required  to  repeat  daily, 
for  short  periods,  slowly  and  deliberately,  word  for  word,  sentences 
pronounced  by  the  teacher.  Singing  and  intonation  prove  easier  methods 
of  expression.  Rhythmical  motions  of  the  limbs  or  body,  as  in  marching 
or  dancing,  may  assist  the  enunciation.  Important  in  the  correction  of 
stuttering  is  deep  inspiration  before  the  beginning  of  a  sentence.  Infinite 
patience  and  perseverance  will  be  necessary  to  overcome  the  confirmed 
habit,  though  many  cases  of  stuttering,  lisping,  or  stammering,  due  to 
hasty  utterance,  are  outgrown  in  later  childhood. 

ECHOLALIA   AND   COPROLALIA. 

Echolalia,  an  explosive  repetition  of  the  last  word  or  syllable  of  a 
sentence,  and  coprolalia,  a  violent  ejaculation  of  profane  or  obscene 
words,  frequently  accompanied  by  involuntary  gesticulations,  are  seen 
occasionally  in  neurotic  children  as  expressions  of  convulsive  tic,  hysteria, 
and  some  cerebral  disorders.  The  requirements  of  treatment  are  improve- 
ment in  hygiene  and  nutrition,  which  are  invariably  defective  in  these 
cases. 


APHASIA  417 

APHASIA. 

Loss  of  speech  is  known  as  aphasia  and  may  be  complete  or  partial, 
transient  or  persistent,  visual  or  auditory.  Many  varieties,  from  an  etio- 
logical classification,  are  recognized,  the  two  best  known  being  sensory 
and  motor  aphasia.  Both  of  these  forms,  of  which  the  motor  is  more 
common,  occur  as  a  result  of  cerebral  lesion,  tumor,  abscess,  or  inflamma- 
tion, which  involves  the  cortical  areas.  Of  these,  the  third  frontal,  first 
temporal,  and  inferior  parietal  convolutions  of  the  left  side,  or  their 
direct  or  associated  tracts,  are  most  often  affected.  In  right-handed  chil- 
dren the  left  side,  in  very  young  children  both  sides,  are  probably  in- 
volved. 

The  prognosis  of  aphasia  from  cerebral  lesions  which  do  not  destroy 
life  is  better  in  children  under  seven  or  eight  years,  before  which  the 
opposite  hemisphere  is  more  likely  to  assume  the  suspended  functions  of 
the  left. 

Temporary  aphasias  are  not  uncommon  after  scarlet  fever,  pneu- 
monia, measles,  whooping-cough,  and  typhoid  fever,  especially  the  last 
named.  In  this  form,  speech  may  be  lost  for  weeks  or  even  months,  the 
function  being  gradually  restored  with  the  return  of  strength.  Tempo- 
rary aphasia,  with  or  without  amnesia,  may  occur  as  the  immediate  result 
of  a  sudden  fright,  fall,  or  blow  upon  the  head  from  which  there  may  be 
no  loss  of  consciousness.  In  the  absence  of  severe  intracranial  lesions, 
return  of  speech  and  memory  may  be  expected. 

Up  to  the  sixth  year,  aphasia  from  deafness  following  acute  infectious 
diseases,  as  scarlet  fever  or  influenza,  is  occasionally  seen.  The  fact  that 
mutism  may  follow  deafness  acquired  after  several  years  of  familiarity 
with  spoken  language  emphasizes  the  importance  of  guarding  the  function 
of  speech  in  all  cases  of  loss  or  impairment  of  hearing.  In  early  childhood 
the  acquired  vocabulary  can  only  be  preserved  by  frequent  use  to  its 
fullest  extent.  Daily  exercises  must  be  begun  as  soon  as  health  will 
permit.  This  should  include  every  word  and  expression  with  which  he  is 
familiar,  that  none  be  lost  from  disuse.  As  absolute  deafness  is  rare, 
even  among  congenital  mutes,  advantage  is  taken  of  the  modicum  of 
perception  of  sound-waves,  through  air  or  bone  conduction,  for  aural 
instruction.  In  many  cases  the  auditory  apparatus  is  sensitive  to 
vibrations  of  a  certain  pitch.  This,  being  determined,  is  utilized  for 
teaching  articulate  language.  The  results  obtained  by  this  method 
are  highly  satisfactory,  but  can  only  be  secured  by  specially  trained 
teachers. 

The  heredity  of  deaf-mutism  seems  to  be  well  established,  though 
occasionally  children  born  of  congenitally  deaf  parents  are  free  from 
the  infirmity. 

MASTURBATION. 

Masturbation  is  in  many  instances  primarily  due  to  a  number  of 
lesions  and  disorders  of  the  genitals.  It  is  also  provocative  of  irritation, 
congestion   and  catarrh  of  the  genital  mucosa,     Very  young  infants, 

27 


418  DISEASES    OF    THE    NERVOUS    SYSTEM 

more  especially  girls,  are  known  to  masturbate,  generally  by  rocking 
or  rolling  with  the  thighs  together,  or  rubbing  the  parts  against  the 
clothing,  floor,  or  furniture.  It  is  very  evident  that  the  habit  originates 
in  irritations  resultant  from  uncleanliness,  or  in  the  genital  disorders 
heretofore  enumerated.  In  later  childhood,  boys  especially  learn  the 
habit  from  older  children.  Its  ill  effects,  aside  from  those  of  local 
disease,  are  seen  in  a  premature  development  of  erethism,  which  paves 
the  way  to  erotic  emotionalism  of  later  years.  Comparison  of  the  visible 
phenomena  of  a  sexual  orgasm  with  an  attack  of  petit  mal  suggests  their 
clinical  similarity,  a  conclusion  which  helps  to  explain  the  morbid  effects 
upon  the  developing  organism  of  a  frequent  occurrence  of  such  cata- 
clysmic intensity. 

The  real  causative  relation  of  sexual  perversion  to  the  practice  of 
masturbation  has  been  much  discussed.  Y/hichever  may  cause  the  other, 
or  whether  each  acting  as  factors  in  a  vicious  circle  intensifies  the 
other,  the  fact  is  generally  acknowledged  that  masturbation  is  a  vice 
fraught  with  peril  to  the  future  well-being  of  its  victim,  and  that  parents 
and  nurses  should  be  ever  on  the  alert  to  prevent  the  inception  of  the 
habit  formed  by  neglect  of  hygiene.  All  possible  causes  of  local  irritation, 
whether  functional,  structural,  or  accidental,  should  be  relieved  by  appro- 
priate means.  Vigilant,  intelligent  surveillance,  with  tireless  self-denial, 
may  be  necessary  on  the  part  of  the  mother  or  nurse  to  divert  the  little 
victim  from  his  newly-found  enjoyment.  Mental  occupation,  with  healthy 
stimulation  to  rational  entertainment,  will  surely  wean  the  normal  child 
from  the  habit  of  self -abuse.  Good  hygiene,  fresh  air,  frequent  bathing, 
clean  clothing,  with  good  digestion,  normal  fatigue,  and  sound  sleep,  are 
curative  agencies.  Sedative  drugs — those  which  reduce  reflex  excitabil- 
ity— may  be  necessary  in  extreme  cases  for  a  short  period.  For  these 
the  best  are  the  bromides,  or  the  monobromide  of  camphor  pill,  in  dosage 
suitable  to  age. 

REFLEXES. 

The  instability  of  the  nervous  system  in  childhood,  due  largely  to 
the  lack  of  development  of  the  higher  or  inhibitory  centres,  not  only 
renders  the  child  susceptible  to  a  variety  of  disorders  of  purely  reflex 
origin,  but  marks  as  peculiar  the  symptomatology  of  all  diseases  of 
childhood.  In  addition  to  this,  the  nervous  centres  are  more  quickly 
exhausted,  and  not  only  show  inability  for  sustained  function,  but 
are  readily  influenced  by  innutrition  from  insufficient  food,  indiges- 
tion, etc. 

The  enormous  demands  for  tissue  growth  interfere  with  function 
upon  the  slightest  impairment  of  food  supply,  so  that  vicious  circles 
are  readily  established  involving  trophic,  motor,  and  secretory  control. 
The  tendency  to  vasomotor  disturbances  from  the  most  trivial  causes 
adds  to  the  functional  confusion  in  the  disorders  of  childhood.  Struc- 
tural changes,  too,  in  the  immature  tissues  follow  hard  upon  derange- 
ments of  function,  so  that  organic  disease,  especially  of  the  nervous 
system,  is  frequently  established  in  the  first  months  of  life. 


REFLEXES  419 

Infancy  and  childhood  is  the  physiological  borderland  of  neuras- 
thenia, while  reflex  neuroses  of  infinite  variety  are  characteristic  of  this 
period. 

General  convulsions  of  purely  reflex  origin  are  common  and  occa- 
sionally fatal.  In  these  the  only  discoverable  cause  may  be  local  irrita- 
tion of  the  intestinal  tract  from  worms  or  undigested  food,  also  from 
adenoids,  foreign  bodies  in  the  ears,  genital  irritation,  or  burns. 

Reflex  spasm  of  the  bladder  may  be  due  to  genital  irritation,  cold, 
and  fright.  Cough,  without  pulmonary  lesion,  may  be  due  to  reflex  irri- 
tation from  chronic  ear  disease,  impacted  cerumen,  or  a  foreign  body  in 
the  external  auditory  meatus,  adenoids,  or  from  irritation  in  the  digestive 
tract.  To  the  same  causes  may  be  due  laryngospasm  and  asthma  of 
alarming  and  persistent  type,  which  yields  only  upon  removal  of  the 
distal  cause. 

Persistent  hiccough  and  alarming  attacks  of  dyspnoea,  with  gasping 
and  cyanosis,  may  be  caused  by  irritation  of  the  diaphragm  from  an 
overloaded  stomach.    Relief  is  obtained  in  such  cases  by  prompt  emesis. 

Recurrent  obstinate  vomiting  is  frequently  of  purely  reflex  origin 
and  may  be  excited  by  many  causes,  as  from  intracranial  pressure,  fright, 
shock,  or  other  sensory  disturbances,  and  also  from  laryngeal  and  pharyn- 
geal irritation,  and  is  frequently  relieved  only  by  the  treatment  of  the 
exciting  cause. 

Functional  tachycardia  is  extremely  common  in  childhood,  especially 
from  the  sixth  to  the  sixteenth  year,  and  is  easily  induced  by  mental, 
emotional,  and  many  physical  conditions. 

Headache  is  very  commonly  of  reflex  origin  as  in  some  ocular  defects, 
such  as  ametropia,  astigmatism,  or  insufficiency  of  the  ocular  muscles. 
Reflex  headache  may  be  induced  through  the  pneumogastric  nerve  by 
hunger  or  gastric  irritation. 

Pathological  processes  in  the  nasopharynx,  in  the  auditory  canal  and 
middle  ear,  also  dental  caries,  especially  in  the  upper  jaw,  may  give  rise 
to  headache.  Headaches  are  occasionally  due  to  irritation  of  the  genitals, 
and  are  often  an  accompaniment  of  early  menstruation. 

REFLEX   DISORDERS   OF   DENTITION. 

Innumerable  reflex  disorders  have  been  attributed  to  dentition,  among 
which  are  irritability,  pyrexia,  cough,  asthma,  laryngospasm,  eoryza. 
headache,  earache,  adenitis,  anorexia,  indigestion,  diarrhoea,  loss  of 
weight,  skin  eruptions,  convulsions,  and  even  death.  The  pernicious 
tendency  to  attribute  all  the  ills  of  later  infancy  to  dentition  has  been 
vigorously  combated  by  pediatrists  for  the  obviously  good  reason  that 
many  infants  are  annually  sacrificed  by  the  neglect  of  some  patho- 
logical conditions,  the  symptoms  of  which  are  erroneously  ascribed  to 
teething. 

Some  able  teachers  in  their  enthusiasm  have  gone  so  far  as  to  assert 
that  teething,  being  a  physiological  process,  could  produce  nothing  but 
teeth,  hence  was  unworthy  of  nosological  recognition.     The  same  reason- 


420  DISEASES    OF    THE    NERVOUS    SYSTEM 

ing  applied  to  parturition  and  several  other  physiological  processes  will 
furnish  a  reductio  ad  absurdum. 

HEADACHE. 

Headache  in  children  is  a  common  accompaniment  of  the  febrile  state 
from  whatever  cause.  It  is  also  a  prominent  symptom  of  graver  forms 
of  intracranial  disease,  and  for  this  reason  its  appearance  in  very  young 
children  should  never  be  lightly  regarded.  Aside  from  the  above  and 
local  circulatory  conditions,  as  congestion  or  ischaemia  of  the  cerebral 
vessels,  the  ordinary  headaches  of  children  may  be  due  to  a  variety  of 
causes,  among  which  are  toxaemia ;  reflex  irritations  from  eyes,  ears,  naso- 
pharynx, teeth,  digestive  tract,  or  genito-urinary  tract;  general  anaemia 
and  malnutrition;   neurotic  tendency;   migraine. 

The  first  class  is  most  often  due  to  absorption  of  toxins  from  the 
alimentary  tract  from  constipation,  overingestion  or  deficient  action  of 
the  emunctories,  or  the  headache  may  be  an  indication  of  serious  renal 
disease.  Systemic  poisoning  may  be  due  to  impure  air,  tea,  coffee,  or  lead 
from  pigments,  confectionery,  and  other  sources ;  also  from  the  toxines  of 
infectious  diseases.  Children  of  rheumatic  or  gouty  heritage  are  espe- 
cially subject  to  toxaemic  headaches. 

The  headaches  of  the  anaemic  and  poorly  nourished  are  known  to  dis- 
appear with  improvement  in  nutrition.  In  underfed  and  overworked 
children  who  are  ambitious  in  school,  or  in  precocious  children  with  capri- 
cious appetities,  headaches  are  common  and  yield  only  to  the  evident 
requirements  of  better  hygiene. 

The  tonic  daily  sponge-bath  followed  by  brisk  friction,  good  ventila- 
tion in  sleeping  apartments,  more  hours  given  to  sleep,  more  exercise 
in  the  open  air,  four  meals  a  day  of  increased  supply  of  animal  food  and 
diminution  in  purely  saccharine  and  farinaceous  articles  are  indicated. 
A  diet  of  eggs,  milk,  meat,  soups  and  broths,  with  cocoa  in  place  of  tea 
and  coffee,  and  limited  application  to  lessons,  music,  art,  or  school  curric- 
ulum, are  recommended.  Many  cases  need  the  judicious  administration 
of  iron  and  arsenic. 

Neurotic  children  with  a  tendency  to  neurasthenia,  hysteria,  chorea, 
or  epilepsy,  are  frequent  sufferers  from  headaches  from  any  of  the  fore- 
going exciting  causes.  In  these  children  general  indisposition  may  fre- 
quently assume  the  form  of  headache  from  imitation,  especially  if  the 
mother  or  older  members  of  the  family  are  subject  to  this  malady.  Too 
much  sympathy  should  not  be  expressed  for  this  class  of  patients,  and 
unobtrusive  mental  and  moral  hygiene  is  the  best  line  of  treatment,  with 
but  little  obvious  medication,  as  the  habits  of  invalidism  and  drug-taking 
are  easily  established. 

Quite  a  number  of  children  are  sufferers  from  migraine,  attacks  of 
which  may  be  precipitated  by  any  or  all  of  the  known  causes  of  headache. 
In  some  cases  the  premonitory  ocular  symptoms,  as  fanciful  and  often 
colored  geometrical  figures,  floating  balls  or  muscae  volitantes,  are  sug- 
gestive of  the  aura  of  epilepsy.     Yawning,  pallor,  nausea,  or  vomiting, 


HEADACHE  421 

hemierania  followed  by  a  profound  sleep,  with  relief  of  headache  in 
twenty-four  hours,  is  characteristic  of  migraine  in  a  child.  So,  also,  is 
periodicity  of  attacks  after  intervals  of  two  or  more  weeks  in  children 
of  otherwise  good  health.  Preceding  the  attack  the  urine  may  be  dimin- 
ished in  quantity  and  show  high  specific  gravity  with  excess  of  solids. 
During  and  immediately  following  the  attack  large  quantities  of  pale 
urine  of  low  specific  gravity  are  passed.  A  distinct  heredity  is  traceable 
in  nearly  all  cases  of  migraine,  and  the  confirmed  victims  of  this  malady 
may  show  remarkable  exemption  from  other  disorders.  Occasionally, 
however,  attacks  of  migraine  are  replaced  by  those  of  epilepsy.  In  later 
life  it  is  known  to  give  way  to  chronic  rheumatic  and  gouty  manifes- 
tations. 

In  the  treatment  of  migraine  a  careful  examination  of  the  eyes  should 
always  be  made,  as  refractive  and  other  ocular  defects  are  very  fre- 
quently associated  with  this  class  of  headaches.  Undoubtedly  the  number 
of  the  attacks  may  be  lessened  and  their  severity  mitigated  by  correction 
of  conditions  knowm  to  favor  headache.  Correct  habits  of  living,  avoid- 
ance of  fatigue  or  excitement,  care  of  the  diet,  attention  to  the  bowels, 
with  the  exhibition  of  saline  aperients,  may  often  anticipate  and  prevent 
an  attack. 

The  list  of  anodynes  for  the  relief  of  the  hemierania  is  a  long  one, 
prima  facie  evidence  of  their  curative  inefficiency.  The  wrecks  of  human- 
ity everywhere  in  evidence  as  a  result  of  drug  habits  for  the  relief  of 
migraine  are  a  standing  admonition  against  the  employment  of  purely 
analgesic  medication  for  a  recurrent,  self-limited  malady  which  never 
endangers  life  nor  threatens  the  integrity  of  organic  function.  The  coal- 
tar  products  may  not  be  administered  to  all  children  with  impunity,  and 
should  never  be  used  except  to  relieve  severe  suffering.  Upon  the  appear- 
ance of  symptoms  of  migraine  the  probability  of  undigested  food  in  the 
stomach  would  suggest  prompt  emesis,  secured  by  copious  draughts  of 
tepid  water,  salt  solution,  or  ipecac  and  soda  bicarbonate,  to  be  followed 
by  evacuation  of  the  bowels  with  magnesium  citrate  or  any  promptly 
acting  saline  laxative.  The  child  should  be  put  to  bed  in  a  well-venti- 
lated, darkened  room.  Dry  heat  to  the  feet  to  improve  the  circulation 
may  be  necessary.  Food  should  not  be  urged.  If  called  for,  a  little 
warm  gruel  or  thin  broth  with  a  cracker  may  be  given.  Hot  or  cold 
applications,  according  to  the  sensation  of  the  patient,  may  be  made  to 
the  head.  If  the  case  be  uncomplicated,  the  paroxysm  will  subside  in 
twenty-four  hours,  usually  after  a  night's  rest. 

MENINGITIS. 

Varieties. — Cerebral  meningitis;  spinal  meningitis;  cerebrospinal 
meningitis ;  pachymeningitis  of  the  dura  ;  leptomeningitis  of  the  pia ; 
meningitis  of  the  convexity  as  distinguished  from  basilar  meningitis. 

From  our  present  knowledge  of  inflammation  and  infection  it  is  diffi- 
cult to  conceive  of  a  meningeal  inflammation  not  due  to  some  specific 
agent, — i.e.,  secondary  to  some  infection. 


422  DISEASES    OF    THE    NERVOUS    SYSTEM 

Metastatic  inflammations  of  the  brain  (meningitides)  have  long  been 
clinically  associated  with  most  of  the  acute  febrile  disorders,  the  exan- 
themata and  visceral  inflammations,  so  that  cerebral  symptoms  and  brain 
complications  have  from  time  immemorial  clouded  the  prognosis  in  most 
of  the  acute  and  many  of  the  chronic  constitutional  disorders. 

Year  by  year  as  various  pathogenic  microbes  are  isolated  in  causative 
relationship  to  meningeal  inflammation,  the  cases  of  so-called  idiopathic 
meningitis  are  narrowed  down  until  the  term  has  come  to  express  merely 
an  absence  of  a  determinate  cause. 

Inflammation  of  the  meninges  may  be  due  to  the  diplococcus  intra- 
cellularis  of  Weichselbaum,  the  tubercle  bacillus,  the  pneumococcus,  the 
streptococcus  pyogenes,  the  typhoid  bacillus,  the  bacillus  coli  communis, 
the  bacillus  pyocyaneus,  and  undoubtedly  a  number  of  other  bacteria. 
Meningitis  is  known  to  follow  or  complicate  measles,  scarlet  fever,  per- 
tussis, influenza,  mumps,  erysipelas,  otitis  media,  arthritic  and  endocar- 
dial inflammations,  catarrhal  lesions  of  the  nasal,  pharyngeal,  or  f  aucial 
mucosa,  also  lesions  and  inflammations  of  the  lower  digestive  tract  as 
well  as  septicaemia,  pyaemia,  and  necrotic  or  suppurative  lesions  in  near 
or  remote  parts  of  the  body.  To  these  may  be  added  trauma,  insolation, 
shock,  and  mental  excitement.  Meningitis  is  the  commonest  of  the  grave 
affections  of  childhood,  and  although  met  with  at  all  ages  it  may  be 
considered  peculiar  to  childhood  and  infancy.  The  first  decade  of  life 
shows  about  seventy-five  per  cent.,  the  first  lustrum  sixty  per  cent.,  and 
the  first  three  years  about  fifty  per  cent,  of  all  cases.  A  few  cases  are 
reported  in  the  first  weeks. 

A  number  of  reasons  are  apparent  for  this  early  prevalence  of  men- 
ingitis. The  susceptibility  of  infants  to  meningeal  inflammations  is  not 
surprising  when  we  consider  their  peculiarities;  the  extensive  mucous 
tract  in  the  relatively  large  tympanum  and  mastoid  antrum,  affording 
cultural  facilities  for  various  pathogenic  bacteria ;  the  easy  access  to  the 
meninges  from  these  cavities  through  their  thin  walls,  through  the  un- 
closed squamopetrosal  suture,  as  well  as  along  the  sheaths  of  nerves 
and  vessels  through  their  several  foramina ;  the  proximity  of  the  large 
venous  sinuses  to  suppurating  foci  and  bony  necrosis,  with  result- 
ing thrombosis;  the  freer  anastomosis  between  the  extra-  and  intra- 
cranial vessels;  the  relatively  rich  supply  and  great  activity  of  the 
lymphatics;  the  vascularity  of  the  meninges  and  adjacent  structures; 
the  lower  resistance  of  only  partially  developed  tissue ;  the  activity  of 
the  cerebral  circulation,  with  the  enormous  metabolism  for  both  function 
and  growth;  the  frequent  occurrence,  from  trifling  causes,  of  extreme 
cerebral  congestion  owing  to  the  undeveloped  vasomotor  apparatus  at  this 
period ;  the  effect  upon  the  limited  lung  capacity  of  pulmonary  lesions, 
in  causing  blood  stasis  in  the  cerebral  veins  and  sinuses  favoring  throm- 
bosis, transudations,  and  infection ;  the  greater  tendency  to  catarrhal 
inflammations  and  adenoid  conditions  of  the  upper  respiratory  mucosa 
affording  cultural  beds  in  close  proximity  to  the  Eustachian  tubes  and 
the  cribriform  foramina;   the  prevalence  in  childhood  of  the  many  in- 


MENINGITIS  423 

fectious  diseases  commonly  associated  with  meningeal  involvement,  and 
the  proverbial  frequency  of  slight  traumatisms  from  falls  and  jars  due 
to  the  helplessness  of  infancy. 

Symptoms. — The  symptoms  of  acute  meningitis  are  those  of  a  general 
intoxication,  to  which  are  added  indications  of  increased  intracranial 
pressure.  Several  varieties,  dependent  upon  the  nature  of  the  infection, 
the  extent  and  location  of  the  meningeal  lesion,  are  recognized.  The 
symptoms  are  sufficiently  common  to  render  unnecessary  a  separate  de- 
scription of  each  variety. 

In  the  acute  forms  the  onset  is  more  or  less  abrupt,  with  headache, 
fever  (101°-104°  F.,  38.5°-40°  C),  prostration  from  anorexia,  restless- 
ness or  even  delirium,  frequent  vomiting  (projectile  type),  photophobia 
and  contracted  pupils,  or  there  may  alternate  dilatation  and  contractions 
(hippus).  Rarely  the  paradoxical  pupillary  reaction  is  observed  (di- 
lating in  the  light  and  contracting  in  the  shadow ) .  There  may  be  slight 
strabismus,  more  frequently  upward,  and  lateral  conjugate  deviation, 
or  nystagmus  may  be  present.  Twitching  of  the  facial  muscles  are  some- 
times premonitory  of  a  general  convulsion.  The  conjunctivas  are  con- 
gested and  lids  are  swollen.  There  is  general  hyperassthesia  with  local 
tenderness  and  pain,  especially  over  the  cervical  and  upper  dorsal  spine. 
The  pulse  may  be  at  first  accelerated,  but  later  is  slow  and  irregular. 
The  bowels  are  usually  constipated,  and  though  constipation  may  per- 
sist the  abdomen  is  retracted,  showing  the  familiar  "  boat-shape"  or 
' '  bread-tray ' '  belly.  The  ' '  tache  cerebrale ' '  may  be  elicited  by  stroking 
the  skin  lightly  with  the  finger.  The  tongue  may  be  furred,  although 
more  often  its  surface  is  clean.  Rigidity  of  the  neck,  with  head  retrac- 
tion, is  common.  More  or  less  spasticity  of  the  limbs  is  observed,  with 
increased  reflex  excitability  and  occasional  paralysis.  If  the  sole  be 
irritated  by  drawing  a  sharp  object,  as  a  pencil,  along  its  surface,  the 
great  toe  may  show  extreme  dorsiflexion,  while  the  remaining  four  are 
plantar-flexed  (Babinski's  phenomenon).  This  reflex  has  no  significance 
in  early  infancy  before  medullation  of  the  pyramidal  tracts.  Initial 
convulsions  are  not  infrequent  and  terminal  convulsions  are  common. 
The  decubitus  of  the  child  is  significant.  To  avoid  the  pain  of  the 
flexion  of  the  rigid  neck  the  patient  lies  upon  his  side  with  head  re- 
tracted and  thighs  and  legs  flexed  upon  the  body  (gun-hammer  position) 
(Fig.  152). 

In  young  infants  bulging  fontanelles  give  evidence  of  increased  intra- 
cranial pressure.  The  distention  of  the  lateral  ventricles  with  fluid  gives 
rise  to  a  tympanitic  note  on  percussion  over  the  frontal  or  parietal  bones 
(Macewen's  sign).  The  closed  eyelids,  corrugated  brows,  dread  of  light, 
and  sharp  cephalic  cry,  are  all  indicative  of  cerebral  pain. 

The  stage  of  excitement  or  delirium  is  succeeded  by  apathy,  stupor, 
or  even  coma.  The  pupils  may  show  inequality  or  tardy  reaction  to 
light.  Ophthalmoscopic  examination  of  the  fundus  reveals  tortuosity 
of  the  retinal  vessels.  There  may  be  partial  or  total  blindness,  the  hear- 
ing is  usually  affected,  and  complete  deafness  may  follow.     As   the 


424 


DISEASES    OF    THE    NERVOUS    SYSTEM 


pressure  increases,  the  pulse  becomes  slow  and  irregular,  while  pupillary 
and  tactile  reflexes  are  abolished.  The  eyes  may  be  wide  open  and  staring 
(Fig.  153),  and  show  rheumy  films  on  the  sclerotic  and  cornea.  The  slow 
and  irregular  respiration  assumes  the  Cheyne-Stokes  type.  The  tempera- 
ture shows  no  characteristic  arc  and  may  be  only  slightly  above  normal. 
Urine  and  fasces  are  passed  involuntarily.  Extreme  opisthotonos  may 
develop.  Kernig's  sign  is  present  in  fully  eighty  per  cent,  of  the  cases. 
This  phenomenon  is  best  obtained  by  placing  the  thigh  at  a  right  angle 
with  the  body,  whereupon  efforts  to  extend  the  leg  will  be  met  by  re- 
sistance and  tremors  if  forced  beyond  an  angle  of  ninety  degrees. 
Before  pupillary  paralysis  occurs,  Squire's  sign  may  be  elicited  in 
the  following  manner :  The  child  lying  on  his  back,  the  head  is  grasped 
firmly  by  the  physician  and  rotated  slowly  backward  to  extreme 
extension.  During  this  act  the  pu- 
pils will  be  seen  to  dilate,  reaching 
their  maximum  in  extreme  extension. 
If  now  the   head  be  brought   for- 


FiG.  152. — Meningitis.    Gun-hammer  position. 


Fig.  153. — Meningitis,  semicoma,  six  Hours  before- 
death. 


ward,  the  pupils  will  contract,  the  extreme  point  being  reached  when 
the  chin  is  pressed  against  the  sternum.  Some  force  may  be  necessary, 
and  the  procedure  is  painful. 

The  coma  may  continue  from  three  to  fifteen  days,  during  which 
time  there  is  increasing  difficulty  of  deglutition,  shallow  respiration, 
weak,  rapid  pulse,  and  general  failure  of  all  the  vital  processes,  with 
one  or  more  convulsions,  followed  by  death.  Sometimes  amelioration 
of  all  the  symptoms  and  partial  return  to  consciousness  precedes  by  a 
day  or  two  the  fatal  termination,  thus  engendering  an  elusive  hope, 
against  which  the  physician  must  be  always  on  his  guard. 

Simple  acute  or  leptomeningitis  is  an  inflammation  of  the  pia  mater 
which,  as  a  rule,  also  involves  the  dura  and  the  gray  matter.  Pus  is 
rarely  found,  the  inflammation  being  essentially  serous,  with  accumu- 


MENINGITIS  425 

lation  of  fluid  in  the  ventricles  and  subarachnoid  space.  The  brain 
substance  may  become  distinctly  cedematous.  The  meninges  of  the  con- 
vexity are  involved,  those  of  the  base  usually  escaping.  Occasionally 
post-mortem  reveals  no  macroscopic  changes  whatever.  The  microscope 
shows  engorgement  of  the  blood-vessels  and  extravasation  of  leucocytes 
in  their  vicinity.  The  pia  may  be  agglutinated  to  the  subjacent  gray 
matter  or  fused  in  places  with  the  dura.  In  the  more  chronic  cases, 
besides  leucocytes,  the  extravasation  may  contain  fibrin,  pus.  and  serum 
in  varying  quantities,  which  go  to  form  a  plastic  exudate  filling  the 
interstices  of  the  convexity  or  base.  This  results  in  the  formation  of 
semi-organized  tissue  with  adhesions  and  sclerosis  of  adjacent  meninges 
and  brain  substance. 

The  duration  varies  greatly  with  the  nature  of  the"  infection  and  the 
form  of  the  disease.  A  fulminating  type  of  the  epidemic  variety  may 
complete  its  course  with  fatal  termination  in  from  twelve  to  forty-eight 
hours,  whereas  the  tuberculous  meningitis,  equally  as  fatal,  may  cover  a 
period  of  from  two  to  twelve  weeks,  showing  remissions  and  ameliora- 
tions. A  meningitis  of  unknown  etiology  may  run  an  average  fatal  course 
in  ten  or  twelve  days. 

Recoveries  are  preceded  by  a  gradual  return  of  intelligence,  deep- 
ened respiration,  subsidence  of  the  fontanelles  in  infants,  improved  deglu- 
tition and  a  general  amelioration  of  all  the  symptoms.  Convalescence 
may  be  protracted  over  a  period  of  weeks  or  months.  Irritability  and 
easily-induced  headaches  are  not  uncommon  for  a  long  time  following 
recovery.  Vision  improves,  though  strabismus  may  persist.  Deafness 
is  not  infrequent,  resulting  in  the  earlier  years  in  mutism.  Occasion- 
ally spastic  paralysis  of  one  limb,  more  often  an  upper,  is  permanent. 
Mental  impairment  of  varying  degree  is  not  an  uncommon  legacy  of 
cerebral  meningitis. 

Although  meningitis  may  be  caused  by  a  number  of  micro-organisms, 
it  is  customary  to  consider  the  disease  as  belonging  to  one  of  three 
varieties, — namely,  tuberculous,  due  to  the  development  of  tubercles 
of  the  pia  mater  at  the  base,  hence  called  basilar  meningitis:  second, 
the  epidemic  form,  due  to  the  diplococcus  intracellularis  of  "Weichsel- 
baum,  which  frequently  involves  the  upper  portion  of  the  spinal  as 
well  as  the  cerebral  pial  membrane,  hence  the  term  cerebrospinal  menin- 
gitis ;  third,  the  so-called  simple  variety,  sometimes  miscalled  idiopathic 
because  of  its  unknown  etiology.  It  is  in  reality  secondary  to  any  of  the 
many  before-mentioned  infections,  the  tuberculous  and  epidemic  varieties 
excepted. 

Tuberculous  meningitis  is  characterized  by  its  insidious  onset  and 
longer  duration.  The  child  may  suffer  for  days  and  even  weeks  from 
general  malaise  and  recurrent  headaches.  Frequently  the  earliest  indi- 
cation of  meningeal  involvement  may  be  night  attacks,  resembling  pavor, 
accompanied  by  a  shrill  scream.  The  mild  prodromata  may  have  at- 
tracted but  little  attention  in  the  busy  household  and  are  only  recalled 
upon  the  development  of  acute  symptoms.     Diagnosis  may  have  been 


426  DISEASES    OF    THE    NERVOUS    SYSTEM 

made  of  worms,  gastro-intestinal  indigestion,  malarial  fever  from  the 
recurrent  pyrexia,  or  more  often  typhoid  fever,  which  it  simulates  in 
the  temperature,  headache,  and  malaise. 

The  symptoms,  beginning  with  temperature,  headache,  sopor,  or 
coma  are  common  to  all  forms  of  meningitis  and  do  not  require  a  sepa- 
rate enumeration.  As  might  be  expected  in  the  tuberculous  form,  with 
its  primary  basic  lesions,  the  symptoms  show  more  extensive  and  per- 
sistent involvement  of  the  cranial  nerves,  with  the  consequent  ocular, 
facial,  and  auditory  disturbances.  The  ophthalmoscope  shows  in  a  few 
cases  (fifteen  per  cent.)  the  presence  of  tubercles  in  the  chorioid.  Since 
the  inflammation  in  the  pia  and  subjacent  structures  induced  by  the 
growth  of  tubercles  is  serous,  rather  than  purulent,  the  transudation  of 
fluid  is  sometimes  enormous,  filling  the  lateral  ventricles  and  the  entire 
subarachnoid  space  throughout  the  brain  and  spinal  column.  This  ac- 
cumulation may  produce  distention  of  the  fontanelle  and  separation  of 
the  cranial  bones  in  early  infancy,  so  that  the  term  acute  hydrocephalus 
is  frequently  applied. 

Cerebrospinal  Form. — The  meningitis  due  to  the  organism  of 
Weichselbaum  occurs  in  epidemics,  though  sporadic  cases  are  not  rare. 
The  symptoms  and  intensity  vary  considerably,  as  in  other  infectious 
diseases,  with  different  epidemics. 

The  onset  is  usually  abrupt.  Abortive  and  fulminating  types  are 
also  recognized.  In  the  former  the  symptoms  suddenly  subside  on  the 
third  or  fourth  day  of  the  attack  and  speedy  recovery  follows.  In  the 
latter,  high  temperature,  convulsions,  delirium,  coma,  and  death,  some 
or  all,  follow  in  quick  succession,  within  a  period  of  a  day  or  two. 
During  these  epidemics,  as  well  as  in  sporadic  cases,  the  pneumococcus 
is  often  found  as  the  apparent  etiologic  organism,  and  the  frequent 
occurrence  of  meningitis  as  a  fatal  complication  of  pneumonia  is  a  note- 
worthy fact  of  increasing  interest.  The  simultaneous  prevalence  of  the 
two  diseases  in  epidemic  form  is  suggestive  of  some  closer  relationship 
than  is  now  known. 

The  name  "spotted  fever"  was  formerly  applied  to  the  epidemic 
cerebrospinal  meningitis  because  of  the  frequent  appearance  of  purpuric 
areas  on  the  ear,  tongue,  palate,  neck,  and  trunk,  varying  in  size  from 
a  split  pea  to  a  half  dollar  (Fig.  154).  These  spots  are  preceded  by  a 
petechial  or  urticarial  eruption  appearing  in  the  first  or  second  day  of 
the  attack.  This  rash  may  be  finely  discrete  or  grossly  confluent,  resem- 
bling measles,  for  which  the  disease  has  been  mistaken.  Herpes  labialis 
also  is  usually  seen  in  an  early  stage. 

The  neck  rigidity  common  to  all  types  is  extended  to  general  opis- 
thotonotic  spasm  in  the  cerebrospinal  form,  while  spastic  rigidities  and 
paralyses  are  more  extensive.  Pain  and  hyperesthesia,  especially  over 
the  spine,  are  more  pronounced.  The  characteristic  lesions  are  those 
of  a  purulent  meningitis  which  may  involve  the  convexity,  base,  and 
spinal  cord.  Septic  endocarditis  and  joint  affections  are  frequent  com- 
plications. 


MENINGITIS 


427 


While  not  considered  strictly  contagious,  instances  are  cited  in  which 
different  members  of  a  family  developed  the  disease  successively.  Dur- 
ing the  prevalence  of  epidemics  the  disease  occurs  in  districts  remote 
and  unassociated,  showing  a  preference,  however,  for  those  where  evi- 
dences of  squalor  and  malhygiene  abound. 

Diagnosis. — In  differentiation,  tuberculous  meningitis  shows  a  slow 
onset,  is  frequently  accompanied  by  tuberculous  history  or  lesions  in 
other  parts  of  the  body.  There  is  a  preponderance  of  cerebral-nerve 
symptoms  and  absence  of  epidemic,  traumatism,  sunstroke,  or  con- 
ditions known  to  favor  metastatic  meningitis.  The  most  valuable 
method  of  differential  diagnosis,  not  only  between  the  various  forms  of 
meningitis  but  from  other  diseases,  is  found  by  examination  of  the 


Fig.  154.— General  purpuric  eruption.    Death  on  the  twelfth  day  of  continuous  convulsions. 

(Dr.  J.  C.  Cook.) 

spinal  fluid  obtained  by  lumbar  puncture.  Increased  pressure  gives 
evidence  of  meningeal  inflammation.  A  clear  fluid  during  the  first  week 
excludes  the  suppurative  or  epidemic  form.  Injection  of  the  fluid  into 
the  peritoneal  cavity  of  the  guinea-pig  may  corroborate  the  diagnosis 
by  the  development  of  tuberculosis  in  the  animal.  A  quicker  method 
of  cultivation  is  obtained  by  injecting  the  suspected  fluid  into  the  mam- 
mary gland  of  the  guinea-pig  during  the  early  period  of  lactation. 
Cultures  of  the  tubercle  bacillus,  when  present,  may  be  obtained  within  a 
few  days  from  the  milk.  The  fluid  of  tuberculous  meningitis  shows  less 
extensive  leucocytosis  than  is  seen  in  the  purulent  form,  though  lympho- 
cytes are  usually  more  numerous.  The  mononuclear  cells  predominate 
in  tuberculous  meningitis.  The  polymorphonuclear  neutrophiles  of  the 
purulent  form  may  largely  disappear  in  a  later  stage.  The  different 
stages  of  the  various  forms  and  the  findings  in  chronic  disorders  of  the 


428  DISEASES    OF    THE    NERVOUS    SYSTEM 

nervous  system  serve  to  render  cytodiagnosis  uncertain  unless  due  regard 
be  paid  to  all  the  attending  conditions.  It  is  claimed  that  more  reliable 
information  is  obtained  from  macroscopic  examination  of  the  clot.  In 
tuberculous  meningitis  the  clot  is  of  firmer  consistency  and  of  lighter 
color,  while  that  of  the  purulent  type  is  yellow,  less  firm,  and  smears 
more  readily. 

The  sediment  in  centrifuged  fluid  may  show,  under  the  microscope, 
pus  cells  enclosing  the  organism  of  Weichselbaum,  or  the  diplococcus 
pneumonia?  may  appear  as  an  extra-cellular  form.  The  presence  of  the 
tubercle  bacillus  may  be  occasionally  demonstrated,  and  when  found 
is  conclusive. 

The  tendency  in  infancy  and  childhood  to  so-called  cerebral  symp- 
toms, not  only  at  the  onset  of  acute  disorders  but  also  during  the  prog- 
ress of  wasting  diseases,  not  infrequently  leads  to  a  diagnosis  of  menin- 
gitis when  no  inflammation  exists.  It  is  extremely  difficult  and  at  times 
impossible  to  make  the  diagnosis  from  the  symptoms  present  at  one 
examination.  The  sequence  of  symptoms  with  the  preceding  history, 
and  the  exclusion  of  all  disorders  that  might  possibly  give  rise  to  the 
phenomena,  will  be  oftentimes  necessary  for  a  diagnosis.  Here  lumbar 
puncture  will  be  of  value.  It  should  be  borne  in  mind,  however,  that 
absence  of  inflammatory  products  in  the  spinal  fluid  does  not  disprove 
the  existence  of  cerebral  meningitis.  Neither  does  the  want  of  pressure 
in  the  spinal  canal,  since  its  communication  with  the  ventricles  of  the 
brain  may  be  cut  off  by  occlusion  of  the  Sylvian  aqueduct.  Sopor,  coma, 
cephalic  cry.  hyperesthesia,  spinal  algesia,  retracted  abdomen,  consti- 
pation, irregular  or  irresponsive  pupils,  photophobia,  strabismus,  neuro- 
retinitis,  deafness  and  dysphagia,  retarded  pulse,  projectile  vomiting, 
slow  irregular  respiration  in  the  presence  of  elevated  temperature,  con- 
vulsions, exaggerated  reflexes,,  or  spasticity,  cervical  or  spinal  opisthoto- 
nos with  Kernig's,  Babinskrs,  and  Squire's  signs,  are  conclusive  evi- 
dences of  meningitis. 

Pneumonia  should  show  increased  respiration  with  rapid  sthenic  pulse 
and  the  physical  chest  signs.  From  typhoid  fever,  with  its  cerebral 
symptoms  and  acute  onset,  sometimes  seen  in  childhood,  the  diagnosis 
may  be  very  difficult.  The  absence  of  opisthotonos,  head  retraction, 
leukocytosis,  herpes,  cerebral  cry.  projectile  vomiting,  and  the  rarity 
of  spasticity  with  the  presence  of  the  usually  distended  abdomen,  the 
initial  epistaxis,  the  dorsal  decubitus,  the  temperature  curve,  and  the 
Widal  reaction,  will  positively  declare  the  typhoid  character. 

Scarlet  fever  shows  the  initial  erythematous  rash  and  accompanying 
angina,  also  pulse  and  respiration  in  keeping  with  the  high  temperature, 
and  frequently  there  are  other  cases  occurring  in  the  same  family  or 
house. 

The  diagnosis  from  influenza  is.  at  times,  impossible.  The  preva- 
lence of  an  epidemic  must  be  taken  into  consideration,  although  this  may 
be  misleading,  as  meningitis  may  be  caused  by  the  Pfeiffer  bacillus. 
In  the  absence  of  actual  meningeal  inflammation,  the  cerebral  symp- 


CEREBROSPINAL    MENINGITIS  429 

toms  of  la  grippe  soon  ameliorate,  at  a  time  when  the  symptoms  of 
true  meningitis  are  intensifying. 

In  uraemic  convulsions  or  coma,  the  history  of  an  antecedent  exan- 
them,  the  presence  of  oedema,  the  absence  of  high  temperature  and  spas- 
ticity, with  suppression  of  urine  or  the  presence  of  abnormal  constit- 
uents, as  albumin  and  casts,  should  exclude  meningitis. 

The  student  should  be  notified  and  the  older  physician  reminded  of 
the  clinical  fact  which  is  frequently  responsible  for  mistaken  interpreta- 
tion of  the  cerebral  symptoms  in  children, — viz.,  that  changes  in  blood- 
pressure  alone  may  produce  temporarily  nearly  all  of  the  symptoms  of 
meningitis.  Thus  the  stasis  due  to  active  congestion  which  ushers  in 
many  acute  disorders  of  childhood,  and  on  the  other  hand  the  cerebral 
ischsemia  which  accompanies  an  exhausting  disease,  such  as  cholera 
infantum,  may  induce  a  ':cerebroid"  condition  or  "meningism."  The 
post-mortems  of  these  cases  show  no  evidence  of  true  inflammation. 

It  is  doubtful  if  full  recovery  ever  follows  tuberculous  meningitis. 
Cerebrospinal  meningitis  shows  a  mortality  varying  with  different  epi- 
demics of  from  forty  to  eighty  per  cent.  In  children  under  three  years 
of  age  recoveries  are  extremely  rare.  Acute  meningitis  from  other 
causes,  as  traumatism,  insolation,  and  infections  of  unknown  etiology, 
show  a  more  hopeful  prognosis  as  to  life.  The  sequelae  of  meningitis 
of  all  forms,  as  spasticity,  plegias  with  contractures,  hydrocephalus, 
ocular  and  visual  defects,  deafness,  mutism,  and  various  grades  of 
mental  impairment,  attest  the  ravages  of  this  most  grave  disease  of 
early  life. 

Treatment. — A  suspected  meningitis  calls  for  absolute  rest  in  bed  in 
a  cool  and  darkened  room, — the  noiseless  slippers,  the  quiet  nurse,  the 
ice-cap  or  Leiter's  coil,  ice-bag  to  spine  if  opisthotonos  be  severe,  free 
purgation  with  calomel  and  salines,  sedatives,  as  warm  baths,  bromides, 
ergot,  chloral,  codeine  or  opium  if  necessarj",  and  persistent  attention 
to  nutrition. 

Pressure  symptoms  may  be  relieved  by  escape  of  cerebrospinal  fluid 
through  lumbar  puncture.  This  may  be  repeated  as  frequently  as  the 
urgency  of  the  symptoms  requires.  Whatever  curative  value  may  be 
claimed  for  this  procedure,  its  immediate  benefits  are  frequently  obvious 
in  the  diminished  severity  of  the  symptoms. 

Iodide  of  potassium  or  sodium  as  a  sorbefacient  should  be  given. 
Indications  of  heart  failure  should  be  met  with  alcohol,  camphor,  or 
digitalis.     Strychnia  should  rarely  be  used  in  this  disease. 

In  difficult  deglutition,  gavage  may  be  employed.  The  maintenance 
of  gastric  digestion  is  so  important  that,  if  threatened,  other  routes  must 
be  employed  for  medication,  as  the  hypodermic  and  rectal. 

To  the  shaved  head  inunctions  of  unguentum  iodoformi  (ten  per 
cent,  in  lanolin),  unguentum  hydrargyri,  or  unguentum  Crede,  applied 
daily,  have  enthusiastic  supporters.  The  same  is  true  of  the  applica- 
tions of  belladonna  ointment,  tincture  of  iodine,  vesicants  and  actual 
cautery  along  the  spine  and  over  the  mastoid.     It  is  doubtful  if  any 


430  DISEASES    OF    THE    NERVOUS    SYSTEM 

procedure  which  increases  the  discomfort  or  interferes  with  the  rest  of 
the  patient  is  of  practical  value. 

Eeeent  experimenters  report  favorably  upon  intraspinal  injections 
of  lysol  and  other  antiseptic  solutions  after  the  reduction  of  pressure  by 
lumbar  puncture.  Further  observations  are  necessary  to  confirm  the 
value  of  this  procedure. 

As  the  convalescence  is  tardy  and  the  susceptibility  to  cerebral  irri- 
tation marked  in  infants  and  children  who  survive  acute  meningitis,  the 
management  of  these  cases  is  of  the  greatest  importance.  To  secure 
absolute  freedom  from  excitement  and  annoyances,  an  entire  change  of 
environment  may  be  necessary.  A  purely  vegetative  condition  in  the 
open  air  is  the  ideal  life. 

For  the  residual  paralyses  and  contractures  daily  gentle  massage 
with  oleaginous  inunctions,  passive  movements,  and  later  the  applica- 
tion of  electricity,  may  do  much  for  the  affected  muscles. 

The  prophylaxis  of  meningitis,  by  careful  attention  to  catarrhal  con- 
ditions of  the  entire  upper  respiratory  tract,  is  of  paramount  impor- 
tance, since  it  is  well  known  that  the  route  of  infection  frequently  lies 
along  the  mucosa  of  the  middle  ear,  nose,  and  accessory  sinuses.  The 
habitual  use  of  cleansing,  antiseptic  and  oil  atomization,  early  attention 
to  adenoid  conditions,  and  prompt  and  thorough  treatment  of  middle- 
ear  inflammations,  will  undoubtedly  lessen  the  frequency  of  meningitis. 

SIMPLE  BASIC  MENINGITIS — INFANTILE  BASILAR   MENINGITIS  OF  NON-TUBER- 
CULOUS  ORIGIN:    POSTERIOR   BASIC    MENTNGITIS. 

Accumulated  reports  have  revived  interest  in  a  form  of  meningitis 
most  frequently  observed  in  infancy.  Like  the  meningitis  due  to  the 
tubercle  bacillus,  it  attacks  the  posterior  portion  of  the  basal  pia  mater. 

It  was  formerly  described  as  cervical  opisthotonos  of  infancy,  for 
which  a  variable  etiology  was  claimed.  The  preponderance  of  evidence 
points  to  the  opinion  that  some  of  the  cases  reported  under  the  above 
titles  were  sporadic  cases  of  cerebrospinal  meningitis.  Other  cases  were 
undoubtedly  of  syphilitic  origin  and  were  cured  by  antisyphilitic  treat- 
ment. Suppurative  otitis  media  is  frequently  held  responsible  for  simple 
basic  meningitis  and  the  opisthotonos  and  other  symptoms  have  been 
known  to  subside  upon  thorough  treatment  of  the  middle  ear  disorder. 

Symptoms. — The  leading  symptom,  to  which  it  owed  its  former  name, 
is  extreme  retraction  of  the  head  with  rigidity  of  the  cervical  and  dorsal 
spine.  All  the  ocular  symptoms  of  meningitis,  including  blindness,  may 
occur,  excepting  optic  neuritis,  which  is  rarely  observed  in  these  cases. 
Bulging  of  the  fontanelles  is  a  pronounced  feature  indicative  of  the 
hydrocephalus,  which  is  a  usual  accompaniment.  Vomiting,  also,  is  com- 
mon and  persistent,  while  diarrhcea  may  replace  the  usual  constipation  of 
meningitis.  The  initial  temperature  is  high.  Muscular  wasting  is  rapid 
and  extreme.  \Vith  the  extreme  opisthotonos  there  is  general  persistent 
rigidity  with  tonic  spasm  of  the  upper  extremities.  Paralysis  is  uncom- 
mon, while  the  pulse   and  respiration   are  not  typical  of  meningitis. 


ENCEPHALITIS  431 

After  the  initial  fever  the  temperature  may  remain  normal  throughout, 
with  terminal  hyperpyrexia  in  fatal  cases.  Irritability  followed  by  hebe- 
tude is  the  rule,  although  coma  is  unusual. 

The  peculiar  pathology  is  basic  exudation  with  agglutination  of  the 
structures  at  the  base  of  the  skull,  as  pons,  medulla,  and  cerebellum. 
Occlusion  of  the  ventricular  foramina  and  canal  occurs,  giving  rise  to 
a  mild  degree  of  internal  hydrocephalus. 

In  the  following  points  it  differs  from  tuberculous  meningitis :  The 
temperature,  after  the  onset,  is  rarely  febrile ;  the  extreme  and  persistent 
cervical  opisthotonos  is  the  most  prominent  symptom ;  the  eyes  are 
staring,  the  lids  retracted,  and  photophobia  is  not  a  feature.  Optic 
neuritis  is  absent.  Constipation  is  rarely  present  and  the  pulse  and 
respiration  are  usually  not  typical  of  meningitis.  There  are  no  evidences 
of  infection  by  the  tubercle  bacillus  in  the  spinal  fluid  or  at  post-mortem 
examination.    Recovery  is  possible. 

The  prognosis  of  non-tuberculous  infantile  basilar  meningitis  is  more 
hopeful  than  in  that  of  any  other  form  at  this  age.  As  before  stated, 
tuberculous  meningitis  is  nearly  always  fatal.  In  epidemic  cerebrospinal 
meningitis  recoveries  under  three  years  are  extremely  rare ;  whereas  the 
infantile  basilar  form,  with  its  longer  average  duration,  according  to 
some  observers,  shows  not  over  fifty  per  cent,  mortality,  although  many 
recorded  recoveries  have  chronic  hydrocephalus  and  permanent  mental 
impairment  as  sequelae. 

Lumbar  puncture  in  these  cases  may  aid  the  diagnosis,  but  its  thera- 
peutic value  is  limited  to  the  relief  of  pressure  in  the  spinal  canal  alone, 
since  the  communication  through  the  ventricular  foramina  is  almost 
always  cut  off  by  exudate. 

The  possibility  of  syphilis  as  a  cause  makes  the  free  use  of  iodides 
and  mercurials  advisable  in  this  class  of  cases.  Furthermore,  the  undis- 
puted sorbefacient  action  of  these  drugs  would  suggest  their  use  on 
account  of  the  characteristic  exudate. 

Early  examination  of  the  ears  in  infants  with  head  retraction,  and 
prompt  puncture  of  the  membrane,  with  thorough  treatment  of  tympanic 
suppuration,  may  in  some  instances  abort  this  form  of  meningeal  attack. 

ENCEPHALITIS CEREBRITIS. 

Acute  non-suppurative  encephalitis  probably  occurs  in  children  both 
with  and  without  meningitis.  It  may  follow  any  of  the  acute  infectious 
diseases,  but  most  frequently  that  of  the  Pfeiffer  bacillus.  Occasionally 
at  post-mortem  there  are  found  scattered  throughout  the  brain  small 
areas  of  inflammation  which  appear  as  softened,  bright  red  spots.  There 
is  general  hyperemia,  but  the  vessels  in  the  area  of  inflammation  are 
enormously  distended,  and  punctate  hemorrhages  are  seen  in  close  prox- 
imity to  their  walls.  Cell  proliferation  is  in  evidence,  not  only  in  the 
vessel  walls  but  in  the  neuroglia  of  the  nerve-tissue.  Other  reports  show, 
instead  of  diffuse  distribution,  a  large  or  small  circumscribed  area  in  one 
lobe,  or  a  group  of  inflammatory  foci  confined  to  a  single  region  of  the 


432  DISEASES    OF    THE    NERVOUS    SYSTEM 

brain.  These  two  forms  of  non-suppurative  ^lesions  represent  two  types 
of  inflammatory  processes, — viz.,  hemorrhagic  and  non-hemorrhagic  en- 
cephalitis. The  length  of  the  intervening  time,  however,  between  the 
development  or  occurrence  of  the  lesion  and  the  opportunity  for  post- 
mortem examination,  will  ever  prove  an  obstacle  to  a  satisfactory  demon- 
stration of  the  precise  pathology  in  the  initial  stage.  Secondary  lesions, 
however,  such  as  porencephaly  and  sclerosis,  especially  where  the  areas 
involved  correspond  with  the  history  of  early  focal  symptoms,  confirm 
the  probability  of  a  non-suppurative,  non-hemorrhagic,  cortical  primary 
encephalitis. 

The  symptoms,  as  might  be  expected,  correspond  to  the  form  and  loca- 
tion of  the  inflammatory  lesion, — focal  symptoms  indicating  its  circum- 
scribed character.  In  the  main,  the  symptoms  of  diffuse  encephalitis, 
when  not  masked  by  those  of  the  primary  disease,  resemble  those  of  an 
acute  non-tuberculous  meningitis.  From  this  it  is,  in  some  instances,  in- 
distinguishable. As  a  rule,  however,  the  onset  is  less  abrupt,  beginning 
with  headache,  vertigo,  and  vomiting,  with  sopor  but  rarely  coma,  and 
occasionally  convulsions,  general  or  local.  The  pulse  and  respiration  are 
not  characteristic  as  in  meningitis.  Paralysis  is  of  more  frequent  occur- 
rence and  may  be  transient. 

Whether  a  primary  cortical  encephalitis,  in  which  the  lesions  are 
analogous  to  the  process  in  the  gray  matter  of  the  anterior  cornu  in  in- 
fantile spinal  paralysis,  may  occur  (in  other  words,  the  possibility  of  an 
acute  polioencephalitis),  is  still  a  mooted  question.  However,  acute 
idiopathic  or  primary  polioencephalitis,  superior  and  inferior,  are  recog- 
nized lesions,  the  areas  involved  being  the  anterior  part  of  the  floor  of 
the  fourth  ventricle  and  the  medulla  respectively.  The  former  presents 
ophthalmic  symptoms,  the  latter  labioglossopharyngeal  symptoms.  Al- 
though rarely  found  in  children,  it  is  mentioned  because  the  general 
symptoms  frequently  resemble  those  seen  in  the  encephalitis  of  influenza. 
The  frequency  of  infantile  cerebral  palsy  and  idiocy  after  traumatisms 
and  infections  is  explained  by  the  peculiar  susceptibility  due  to  the  state 
of  immaturity,  lack  of  cranial  support,  and  great  vascularity  of  the 
fetal  and  infant  brain. 

The  treatment  of  encephalitis  in  general  is  the  same  as  that  of 
meningitis. 

INSOLATION — SUNSTROKE;    HEAT   PROSTRATION;    THERMIC   FEVER. 

Hyperpyrexia  from  prolonged  exposure  to  heat  is  common  in  early 
life,  although  the  proportion  of  children  in  the  recorded  cases  of  insola- 
tion for  all  ages  is  insignificant.  Premature  or  even  vigorous  infants 
may  show  a  temperature  of  105°  to  107°  F.  (40.5°-42°  C.)  from  prolonged 
proximity  to  a  hot  stove  or  hot-water  bottles.  Undoubtedly  heatstroke 
is  frequently  overlooked  in  infancy  and  young  children,  the  prostration 
being  attributed  to  intoxication  from  some  slight  disorder,  such  as  sum- 
mer complaint,  etc.  It  is  not  possible,  nor  indeed  necessary,  at  all  times 
to  exclude  pre-existing  disorders  before  making  a  diagnosis  of  heat- 


INSOLATION  433 

stroke.  A  sudden  development  of  hyperexia,  temperature  105°  to  108° 
F.  (40.5°-42.2°  C),  with  history  of  exposure  to  high  temperature  and 
humidity,  followed  by  great  prostration,  with  coma  or  convulsions,  is 
always  suggestive  of  insolation,  although  it  may  prove  to  be  an  initial 
stage  of  almost  any  of  the  infectious  diseases  of  childhood.  The  definite 
etiology  of  sunstroke  is  unknown,  although  a  debilitated  condition  from 
any  cause  is  recognized  as  predisposing.  Prolonged  intense  heat  is 
always  the  dominating  factor  in  the  exciting  cause. 

In  heatstroke  there  is  meningeal  congestion  with  varying  degree  of 
general  venous  engorgement  and  superficial  capillary  stasis.  At  first  the 
child  may  show  a  rapid  sthenic  pulse,  hot  and  dry  skin,  flushed  face,  and 
contracted  pupils,  accompanied  by  headache  and  perhaps  vomiting,  with 
or  without  diarrhoea.  The  temperature  is  high,  103°  to  107°  F.  (39.5°-42° 
C),  with  malaise,  delirium,  or  prostration.  Somnolence,  coma,  or  con- 
vulsions may  ensue,  with  dilated  pupils,  strabismus,  rapid  thready  pulse, 
dyspnoea,  and  cyanosis,  with  increasing  hyperpyrexia,  followed  by  death 
in  less  than  twenty-four  hours. 

Early  energetic  treatment  may  reduce  the  temperature,  restore  con- 
sciousness, and  lead  to  convalescence  in  two  or  three  days.  A  moderate 
degree  of  pyrexia  may  continue  for  several  days — a  form  known  as 
thermic  fever — and  the  child  may  finally  succumb  to  general  intoxica- 
tion or  to  failure  of  heart  or  respiration. 

The  blood  at  first  shows  high  haemoglobin  (125  per  cent.),  and  an  in- 
creased number  of  erythrocytes  (5,300,000).  This  concentration  of  the 
blood  has  been  attributed  to  excessive  perspiration.  Later  the  evidences 
of  haemolysis  are  unmistakable.  Petechia?  frequently  appear  on  the 
limbs  and  trunk  and  hemorrhages  may  occur.  As  erythrocytes  are  not 
decomposed  by  the  degree  of  heat  observed  in  these  cases,  the  haemolysis 
must  be  due  to  some  toxin  produced  in  the  changed  metabolism  under 
the  influence  of  extreme  heat. 

The  post-mortem  shows  venous  engorgement,  with  dark,  subalkaline 
blood,  subpial  oedema,  and  increase  of  fluid  in  the  ventricles. 

A  microbic  hypothesis  has  been  advanced  from  cellular  changes  simi- 
lar to  those  of  known  bacterial  origin.  Other  resemblances  to  microbic 
disease  are  cited,  such  as  its  geographic  distribution,  its  occurrence  in 
epidemic  form,  its  appearance  under  certain  thermic  and  atmospheric 
conditions,  with  tendency  to  relapse.  However,  the  one  condition  essen- 
tial for  its  occurrence  is  unusually  extreme  heat. 

Among  the  sequelae  are  pneumonia,  nephritis,  recurrent  headaches, 
especially  on  slight  exposure  to  heat,  cerebral  hemorrhage,  encephalitis, 
and  meningitis.  Some  of  these,  particularly  the  latter,  may  follow  so 
closely  as  to  raise  the  question  as  to  their  primary  or  secondary  im- 
portance. 

Diagnosis. — The  diagnosis  of  a  sthenic  form  of  sunstroke  from  a  ful- 
minating meningitis  may  be  very  difficult.  The  history  of  exposure  to 
heat,  followed  by  hyperpyrexia  and  cerebral  symptoms  without  paraly- 
sis, points  to  heatstroke.    It  is  not  improbable  that  extreme  thermic  con- 

28 


434  DISEASES    OF    THE    NERVOUS    SYSTEM 

ditions  may  modify  the  onset  of  any  disorder  of  infancy  so  as  to  present 
symptoms  of  insolation. 

Prognosis. — Mild  cases  recover  with  but  little  treatment  save  rest  and 
cold  applications  to  the  head,  although  the  tendency  to  headaches  from 
subsequent  exposure  to  heat  or  the  sun 's  rays  is  peculiar  to  all  forms.  It 
is  difficult  to  estimate  the  mortality  in  infancy  and  childhood,  for  the 
reason  that  probably  many  cases  are  not  recognized.  Reports  of  severe 
uncomplicated  sunstroke  show  about  fifty  per  cent,  of  fatalities. 

Treatment. — The  efficiency  of  the  treatment  depends  largely  upon  its 
early  initiation.  It  is  one  of  the  few  disorders  in  which  reduction  of  the 
hyperpyrexia  is  the  prime  object.  The  condition  presented  is  that  of  ex- 
cessive heat  production  from  unusual  chemical  changes,  with  retarded 
radiation  from  capillary  stasis  and  atmospheric  conditions.  Prompt 
reduction  by  cold  applications  is  indicated.  At  the  same  time  the  cir- 
culation, especially  where  there  is  a  tendency  to  collapse,  must  be  main- 
tained by  appropriate  stimulation.  An  ice-cap  should  be  applied  to  the 
head,  the  child  should  be  stripped,  wrapped  in  a  blanket,  and  placed 
in  a  bath  of  60°  F.  (15.5°  C.)  to  which  cracked  ice  is  rapidly  added. 
Constant  friction  should  be  applied  to  the  trunk  and  extremities.  If 
comatose,  cold  water  may  be  poured  upon  the  forehead  from  a  height, 
as  the  shock  aids  the  friction  in  promoting  cutaneous  circulation.  Cold- 
ness of  the  extremities  calls  for  applications  of  heat  or  mustard  poul- 
tices to  the  feet  and  legs.  Aromatic  spirits  of  ammonia  should  be  given, 
and,  in  persistent  cyanosis,  nitroglycerin  for  the  relief  of  vasomotor 
spasm.  The  tubbing  and  friction  with  ice  should  be  kept  up  until  the 
temperature  shows  signs  of  subsidence.  If  this  be  rapid  the  child  should 
be  removed  from  the  tub  before  the  temperature  reaches  100°  F.  (38° 
C),  as  it  may  become  subnormal.  Digitalis,  by  mouth  or  hypoder- 
mically,  may  be  necessary  to  sustain  the  heart.  Strychnia  is  contra- 
indicated.  Copious  enteroclysis  with  cold,  normal  salt  solution  may  be 
employed  for  heat  reduction  and  to  free  the  bowel  from  toxic  material. 
Spiritus  mindereri,  with  free  administration  of  water,  is  useful  for  its 
diuretic  and  diaphoretic  effect.  Tea  or  coffee  may  be  necessary,  or  even 
alcoholic  stimulation.  The  temperature  per  rectum  must  be  watched, 
and  any  elevation  above  102°  F.  (39°  C.)  should  call  for  a  renewal 
of  the  hydrotherapy.  In  less  severe  cases  tepid  sponging  may  be  suffi- 
cient, always  with  ice  to  head,  or  sprinkling  the  child,  covered  by  a 
sheet,  from  a  watering-pot  held  some  distance  above  the  bed.  In  coma 
the  water  may  be  made  to  impinge  with  force  against  the  skin  to  stimu- 
late the  capillaries.  The  child  will  require  careful  watching  for  several 
days  to  guard  against  rise  of  temperature,  collapse,  and  pneumonia. 

The  diet  should  be  restricted  to  liquids  until  convalescence  is  estab- 
lished. 

THROMBOSIS   OP   THE    CRANIAL   SINUSES. 

Formation  of  a  thrombus,  with  complete  or  partial  occlusion  of  the 
intracranial  sinuses,  is  by  no  means  rare  in  infancy  and  childhood. 


THROMBOSIS   OF   THE    CRANIAL    SINUSES  435 

The  causes  of  thrombosis  have  been  ascribed  to  increased  density  of 
the  blood,  as  after  exhausting  diarrhoeas;  to  roughening  of  the  sinus 
walls;  to  emboli  in  the  blood  stream;  to  pressure  upon  the  vessels  by 
tumors  and  exudates,  and  to  any  condition  which  causes  retardation  of 
the  blood-current,  as  in  mechanical  obstruction  from  an  incompetent 
heart. 

It  is  evident  that  in  the  presence  of  any  or  all  of  the  first  three  men- 
tioned conditions,  the  occurrence  of  either  of  the  last  two,  or  purely 
mechanical  conditions,  would  act  as  an  exciting  cause. 

Thrombosis  may  be  acute  or  subacute  in  its  development.  If  parietal 
and  slow  in  its  formation,  the  sinus  being  only  partly  occluded,  the 
resultant  diminution  in  the  blood-current  would  produce  effects  gradual 
in  their  development,  with  symptoms  difficult  of  recognition  and  con- 
tinuous for  an  indefinite  period.  Sudden  and  complete  occlusion  of  a 
sinus  produces  immediate  stasis  in  vessels  and  areas  beyond  the  obstruc- 
tion. This  results  in  venous  engorgement,  oedema,  and  capillary  hemor- 
rhages. 

If  infection  be  a  cause  or  accompaniment  of  the  process,  emboli  dis- 
lodged from  the  coagulum  may  be  swept  to  distant  parts  of  the  body 
with  resultant  abscesses.  The  lungs  from  their  anatomical  neighborhood 
are  especially  liable  to  these  metastatic  abscesses. 

Two  general  varieties  are  recognized, — viz.,  cachectic  and  infectious, 
the  distinction  being  based  upon  their  apparent  etiology.  Cachectic 
thrombosis  most  commonly  occurs  after  exhausting  disease,  as  enteri- 
tis or  typhoid  fever.  Its  most  constant  location  is  in  the  superior  longi- 
tudinal sinus.  The  symptoms  of  occlusion  of  this  vessel  appear  as  venous 
distention  and  cedema  of  the  scalp  and  bulging  fontanelle.  This  is 
especially  significant  if,  during  the  course  of  the  primary  disease,  it  has 
been  depressed.  Headache,  somnolence,  coma,  and  occasionally  convul- 
sions and  paralysis — in  fact,  the  general  symptoms  of  acute  meningitis 
— may  attend  the  formation. 

Septic  thrombosis  most  frequently  develops  in  the  lateral  or  petrosal 
sinuses  or  in  the  tributary  veins,  the  radicles  of  which  drain  the  capil- 
laries of  the  mastoid  and  tympanic  circulation.  It  constitutes  a  danger- 
ous and  not  infrequent  complication  of  mastoid  and  middle-ear  disease, 
and  is  especially  apt  to  follow  caries  of  the  mastoid  or  petrous  bones. 
Tenderness  or  oedema  behind  the  ear,  retraction  of  the  head  and  stiffness 
of  the  neck,  are  among  the  early  symptoms  of  petrosal  or  sigmoid  throm- 
bosis and  should  be  watched  for  in  all  tympanic  suppurations.  In  com- 
plete occlusion  the  clot  may  extend  to  and  fill  the  internal  jugular  and 
be  felt  as  a  cord,  while  the  external  jugular  may  be  full  and  tense  from 
the  extra  work  imposed  upon  it.  Thrombosis  in  the  cavernous  sinus  may 
be  due  to  infections  from  the  face,  nose,  or  orbit,  through  the  veins  which 
drain  these  areas.  Stasis  in  the  superficial  veins  of  the  face,  epistaxis, 
exophthalmos,  external  strabismus,  ptosis  mid  oedema  of  the  lids,  occur- 
ring suddenly,  are  suggestive  symptoms  of  cavernous  thrombosis.  Optic 
neuritis  is  occasionally  seen  as  a  later  symptom.     These  symptoms  are 


436  DISEASES    OF    THE    NERVOUS    SYSTEM 

usually  unilateral,  but  both  sides  may  be  affected.  Occlusion  of  the 
straight  sinus  blocking  the  veins  of  Galen  results  often  in  hemorrhage 
into  the  lateral  ventricles.  If  extensive,  this  will  simulate  internal 
hydrocephalus. 

Diagnosis. — The  diagnosis  from  abscess  or  meningitis  is  difficult,  and 
the  latter  may  precede  or  accompany  thrombosis.  Points  in  differentia- 
tion of  the  non-septic  variety  from  acute  meningitis  are  the  absence  in 
the  former  of  fever,  characteristic  slow  pulse,  irregular  respiration,  con- 
stipation, and  retracted  abdomen. 

Prognosis. — The  duration  of  a  slowly  developing  thrombus  is  not 
easily  determined.  The  prognosis  as  to  duration  depends  upon  the  char- 
acter of  the  thrombus  and  its  method  of  development.  When  due  to  the 
altered  condition  of  the  blood,  it  may  be  the  terminal  complication  of 
some  acute  disease  and  explains  many  of  the  later  cerebral  symptoms  fre- 
quently attributed  to  meningitis.  Infective  thrombosis  adds,  to  the  dan- 
gers of  local  congestion  and  anaemia,  sepsis  in  the  tissues  of  the  brain 
and  other  organs.  Thrombosis,  as  distinguished  from  "meningism,"  so 
frequent  in  the  later  stages  of  wasting  diseases,  should  be  suspected 
when  there  is  distention  of  the  veins  of  the  face  and  head,  epistaxis, 
definite  paralysis,  and,  in  infants,  prominence  of  a  previously  depressed 
fontanelle.  Parietal  and  slowly  developing  thrombi  may  persist  for 
months  or  years  before  occlusion  is  followed  by  fatal  termination. 

Treatment. — The  prognosis,  if  medical  treatment  only  is  relied  upon, 
is  fatal.  Surgery  promises  much  when  the  location  of  the  thrombus  ren- 
ders it  operable.  This  is  especially  true  of  lateral  and  petrosal  thrombi 
in  connection  with  mastoid  and  tympanic  disease.  In  acute  or  chronic 
otitis  sudden  cessation  of  the  discharge,  with  headache,  rigor,  coma,  or 
convulsions,  warrant  immediate  operation,  not  only  for  the  release  of 
mastoid  or  extradural  pus,  but  as  exploratory  of  the  adjacent  sinuses. 
Clots,  if  present,  should  be  removed.  The  percentage  of  recoveries  in 
such  operations  is  steadily  increasing. 

Prophylactic. — However  brilliant  the  achievement,  the  physician's 
duty  is  but  half  performed  in  the  diagnosis  and  location  of  sinus  throm- 
bosis. He  should  endeavor  to  prevent  the  catastrophe  in  all  conditions 
known  to  favor  its  development.  In  marasmic  conditions,  support  of 
the  heart's  action  by  food  and  stimulants  when  needed,  as  well  as  main- 
tenance of  the  volume  of  blood  by  saline  solutions  injected  into  colon  or 
under  the  skin,  may  prove  prophylactic.  During  infections  of  the  throat 
and  ear  especially  does  the  responsibility  of  warding  off  this  complica- 
tion rest  heavily  upon  the  attending  physician. 

TUMORS   OF    THE   BRAIN. 

Tumors  of  the  brain  are  not  rare  in  early  life  and  have  been  found 
at  birth.  Many  cases  diagnosed  as  hydrocephalus  are  undoubtedly  due 
to  tumors.  So,  also,  meningitis,  tuberculous  or  otherwise,  may  be  the  last 
expression  of  cerebral  neoplasms. 

Aside  from  tuberculosis  and  traumatism,  the  etiology  of  brain  tumor 


TUMORS    OF    THE    BRAIN  4:i7 

is  obscure.  Syphilis,  a  frequent  cause  in  adults,  rarely  shows  gummata 
in  infancy  and  early  childhood,  and  may  only  be  mentioned  as  a  remote 
possibility.  The  frequent  occurrence  of  blows  on  the  head  and  falls  in 
the  histories  of  children  with  brain  tumors  is  held  lightly  by  some  as 
common  to  the  histories  of  all  children,  but  must  still  be  regarded  as 
of  etiological  importance.  The  relation  of  the  location  of  the  tumor  to 
the  site  of  traumatism  is  frequently  suggestive  of  at  least  an  exciting 
causal  connection.  External  neoplasms,  as  of  the  scalp,  and  cranial  ori- 
fices have  been  known  to  cause  brain  tumors  by  inward  extension  of 
growth.  Tuberculosis  is  probably  responsible  for  more  than  half  the 
number  of  intracranial  tumors  found  in  young  children.  The  tubercles 
may  develop  in  a  large  solitary  mass  or  may  appear  as  multiple  lesions, 
varying  in  diameter  from  one  to  fifty  millimetres.  The  most  common 
sites  are  the  cerebellum  and  basal  meninges.  They  are  always  secondary 
to  tuberculous  lesions  in  other  parts  of  the  body. 

In  a  diminishing  order  of  frequency,  brain  tumors  have  been  re- 
ported as  gliomatous,  sarcomatous,  cystic,  and  carcinomatous.  Gliomata, 
unlike  tuberculosis  and  sarcomata,  select  the  white  matter,  are  conse- 
quently deep-seated,  and  rarely  involve  the  meninges.  Cysts  of  parasitic 
origin  are  rarely  found  in  this  country,  although  occasionally  reported 
by  foreign  observers.  More  rarely  the  teratomata  and  mixed  forms  are 
found. 

Symptoms. — The  symptoms  are  general  and  local.  The  general  symp- 
toms are  entirely  independent  of  the  nature  of  the  growth;  they  are 
due  to  intracranial  pressure  and  as  such  correspond  to  other  cerebral 
lesions,  as  meningitis  or  hydrocephalus.  The  rate  of  growth  is  more 
important  in  the  production  of  symptoms  than  the  nature  or  size; 
as  a  small  though  rapidly  developing  tumor  causes  greater  disturb- 
ance than  a  much  larger  neoplasm  of  slow  increase.  Cessation  of 
symptoms  followed  by  exacerbation  is  not  uncommon  in  the  history  of 
tumors.  These  evidently  mark  alternating  periods  of  growth  and  qui- 
escence. In  fact,  a  latent  tumor,  especially  if  in  the  centrum  ovale,  may 
exist  for  a  long  time  without  symptoms.  Post-mortems  occasionally 
reveal  the  presence  of  tumors  entirely  unsuspected  during  life. 

Among  the  most  frequently  observed  symptoms,  in  the  order  of  their 
occurrence,  are  headache,  vertigo,  vomiting,  optic  neuritis,  psychic  dis- 
turbances, or  general  convulsions.  The  headache  is  persistent,  usually 
severe,  and  may  be  very  intense.  It  frequently  shows  a  diurnal  period- 
icity, occurring  with  greatest  severity  during  the  night  or  early  morning 
hours.  Closely  associated  with  headache  are  vertigo  and  vomiting.  The 
vomiting  is  of  the  projectile  type  and  may  occur  independently  of 
meals.  Ordinary  "sick  headache"  from  dyspepsia  may  simulate  these 
phenomena  for  a  day,  but  subsides  quickly  and  yields  to  appropriate 
treatment.  The  persistence  of  this  group  of  symptoms  is  very  suggestive 
of  an  intracranial  growth.  Optic  neuritis  accompanies  brain  tumor  in 
about  eighty  per  cent,  of  cases.  A  review  of  a  large  number  of  reports 
of  choked  disks  shows  ninety  per  cent,  due  to  brain  tumors. 


438  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  most  common  psychic  disturbances  are  irritability  or  excita- 
bility, moroseness  or  somnolency.  The  latter  symptom,  if  persistent, 
increasing,  and  associated  with  headache  and  obstinate  vomiting,  should 
put  the  practitioner  on  his  guard. 

General  convulsions  of  an  epileptic  type  are  observed  in  at  least  half 
the  cases,  occasionally  as  precursory  of  all  other  evidences  of  a  new 
growth,  although,  like  the  headache  and  vomiting,  they  may  disappear 
in  the  terminal  stage  when  condensation  of  tissue  adjacent  to  a  rapidly 
developing  tumor  may  have  been  succeeded  by  a  zone  of  softening  and 
disintegration.  In  young  infants  there  may  be  enlargement  and  asym- 
metry of  the  cranium. 

Special  or  focal  symptoms  are  those  mainly  due  to  the  destruction 
or  embarrassment  of  nervous  tissue  immediately  involved  in  the  neo- 
plastic process,  to  local  pressure,  or  stretching  by  displacement  of  nerve 
roots.    Focal  symptoms  are  absent  in  about  one-fourth  of  the  cases. 

The  bilateral  structure  of  the  brain  explains  the  development  of  uni- 
lateral symptoms  dependent  upon  the  location  of  the  morbid  growth.  If 
this  be  above  the  point  of  decussation,  the  focal  symptoms  will  be  mani- 
fested upon  the  side  opposite  the  lesion.  A  central  location  or  a  degree 
of  enlargement  sufficient  to  involve  both  sides  of  the  brain  would  occasion 
bilateral  symptoms,  so  that  the  extent  and  direction  of  enlargement  may 
be  indicated  by  the  successive  disturbances  of  functions.  Thus  a  uni- 
lateral disturbance  becomes  bilateral  as  the  tumor  encroaches  on  the 
other  hemisphere  or  line  of  conduction.  Since  the  internal  capsule  in- 
cludes all  the  cortical  fibres,  both  motor  and  sensory,  a  moderate-sized 
tumor  in  this  area  (or  in  the  basal  ganglia  and  lateral  ventricles  on 
account  of  their  proximity  to  the  internal  capsule)  necessarily  produces 
extensive  and  complicated  symptoms.  If  'disturbance  of  sensation  ac- 
company motor  symptoms,  there  is  involvement  of  the  posterior  as  well 
as  the  middle  portion  of  the  internal  capsule.  A  tumor  of  the  pons, 
where  the  nerve-fibres  are  crowded  into  a  limited  area,  may  affect  large 
and  varied  extents  of  distribution. 

The  most  easily  recognized  focal  symptoms  are  disturbances  of  the 
motor  function  which  accompany  a  tumor  in  the  cortex.  Thus  a  growth 
in  the  Rolandic  area  may  cause  tremors,  Jacksonian  epilepsy,  or  a  tran- 
sitory hemiplegia  of  the  opposite  side.  If  the  neoplasm  primarily  involve 
the  cortex,  convulsions  appear  early  in  the  history.  If  subcortical  within 
the  white  tissue,  paralysis  may  develop  without  convulsions,  the  occur- 
rence of  which  at  a  later  period  notes  the  inclusion  of  the  gray  matter 
in  the  morbid  process.  The  same  is  true  of  headaches,  which,  as  a  pri- 
mary symptom,  point  to  early  cortical  and  meningeal  involvement.  De- 
veloping later,  they  mark  the  progress  of  growth  towards  the  periphery. 
Stretching  of  the  dura  mater  is  considered  the  most  prolific  cause  of 
cephalalgia  in  intracranial  affections. 

Perversions  of  function,  such  as  word-blindness  and  amnesic  aphasia, 
■show  involvement  of  the  third  frontal  convolution  of  the  left  side  in 
older,  right-handed  children.    This  symptom  is  not  found  in  infants  and 


TUMORS   OF   THE   BRAIN  439 

young  children  before  the  age  of  speech  or  prior  to  the  restriction  of 
speech  function  to  one  hemisphere, — i.e.,  about  the  eighth  year. 

Tumors  of  the  crura  cerebri  may  cause  eye  symptoms,  such  as  disturb- 
ance of  pupillary  reflex,  nystagmus,  strabismus,  also  crossed  paralysis. 
in  which  involvement  of  the  third  nerve  occurs  on  the  side  of  the  lesion 
associated  with  hemiplegia  of  the  opposite  side.  Crossed  paralysis  is  also 
caused  by  tumors  of  the  pons,  the  cranial  nerve  disturbance  appearing  on 
the  side  of  the  lesion ;  sensory  and  motor  disturbance  of  the  extremities 
appear  on  the  opposite  side.  Facial  neuralgia,  corneal  ulceration,  exter- 
nal strabismus,  pupillary  dilatation  and  ptosis  from  involvement  of  the 
third  and  fifth  nerves,  indicate  upper  pontine  lesion.  Deafness,  facial 
paralysis,  contracted  pupils,  and  internal  strabismus  show  implication 
of  the  sixth,  seventh,  and  eighth  nerves  from  tumor  of  the  lower  pons. 

In  all  these  tumors  of  the  base  of  the  skull,  headache,  optic  neuritis, 
and  vomiting  are  common,  although  convulsions  are  rare. 

Labioglossolaryngeal  paralysis  is  always  suggestive  of  a  tumor  of 
the  medulla  and  when  associated  with  glycosuria,  polyuria,  optic  neu- 
ritis, projectile  vomiting,  and  headache,  the  diagnosis  is  confirmed.  The 
last  five  mentioned  symptoms  serve  to  differentiate  tumor  from  degen- 
erative bulbar  paralysis. 

More  than  half  the  intracranial  tumors  of  childhood  are  cerebellar, 
of  which  probably  eighty  per  cent,  are  tuberculous.  As  equilibration  is 
one  of  the  principal  functions  of  the  lesser  brain,  so  evidences  of  such 
disturbances  are  almost  pathognomonic  of  disease  of  this  organ.  This 
symptom  is  known  as  cerebellar  ataxia,  the  result  of  incoordination 
confined  chiefly  to  the  lower  extremities.  The  patient  walks  with  a 
staggering  gait,  likened  to  that  of  a  drunken  man,  or  is  unable  to  even 
stand,  but  shows  a  tendency  to  fall  forwards  or  backwards.  These  symp- 
toms usually  point  to  disease  of  the  central  lobe.  Next  in  importance  to 
the  ataxia  are  vertigo  and  headache.  The  latter  is  usually  occipital  in 
location,  the  best  illustration  of  focalized  headache  in  intracranial  lesions. 

A  tumor  located  in  one  of  the  lateral  cerebellar  lobes  will  cause  the 
patient  to  incline  or  fall  towards  the  affected  side  when  walking.  Not 
infrequently  a  coarse  intention  tremor  is  present  in  the  arm  on  the  same 
side  as  the  lesion.  This  symptom  is  produced  by  fibres  leading  from  the 
cerebellum  through  the  red  nucleus  of  the  opposite  side  to  the  motor- 
centres  of  the  arm  in  the  cortex  of  the  brain.  This  irritation  produces 
the  tremor  of  the  hand  on  the  opposite  side  or,  in  other  words,  on  the  side 
of  the  lesion.  In  these  cases  if  the  child  be  instructed  to  turn  the  wrists 
it  will  be  noticed  that  he  cannot  rotate  the  wrist  of  the  affected  side  as 
rapidly  as  the  other,  and,  after  rotating  the  wrists  for  a  few  moments, 
if  the  patient  stretches  them  above  his  head,  that  wrist  will  involuntarily 
continue  the  rotary  motion  for  a  short  period. 

Bound  down  by  the  firm,  unyielding  tentorium  above  on  its  dorsal 
surface,  enlargement  from  tumor  growth  causes  impingement  of  its 
ventral  surface  against  the  medulla,  pons,  corpora  quadrigemina,  and 
all  the  cranial  nerves;   so  that,  in  addition  to  the  ataxia,  there  may  be 


440  DISEASES    OF    THE    NERVOUS    SYSTEM 

present  any  of  the  symptoms  of  disturbance  of  these  parts,  including 
hemiplegia.  This,  however,  is  rare.  Advanced  cases  may  show  retraction 
of  the  head.  A  peculiar  symptom  of  cerebellar  tumor  is  seen  in  the 
so-called  forced  attitudes,  possibly  due  to  pressure  on  the  middle  cere- 
bellar peduncles.  In  this  the  patient  inclines  his  head  or  body  to  one 
side.  Tenderness  may  be  elicited  by  pressure  or  percussion  of  the  skull 
over  the  seat  of  growth. 

Diagnosis. — The  diagnosis  of  intracranial  lesion  depends  upon  the 
persistence  of  certain  symptoms,  mainly  those  indicative  of  increased 
pressure.  Since  a  number  of  diseases,  such  as  meningitis,  hydrocephalus, 
abscess,  and  hemorrhage,  may  cause  these  symptoms,  the  differentiation 
of  tumor  is  often  difficult  and  sometimes  impossible.  Especially  is  this 
true  when  hemorrhagic  meningitis  or  hydrocephalus  occur  as  compli- 
cations of  the  new  growths. 

In  hemorrhage  there  is  a  sudden  onset  of  symptoms,  apoplectiform  in 
character,  coma,  and  paralysis.  Optic  neuritis,  vomiting,  vertigo,  and 
mental  changes  are  absent.  Localized  or  Jacksonian  epilepsy,  the  pres- 
ence of  choked  disk,  vertigo,  vomiting,  and  persistent  headache,  are 
points  upon  which  to  base  a  diagnosis  of  tumor.  The  persistency  and 
increasing  severity  of  the  symptoms  in  tumor  are  in  marked  contrast  to 
the  improvement  from  apoplectic  seizures. 

Slowly  developing  basilar  meningitis  may  simulate  tumor  very 
closely.  Large  tubercular  masses  may  constitute  the  new  growth.  The 
differentiation  between  cerebral  meningitis  and  tumor  should  be  made 
by  the  absence  in  the  latter  of  fever,  constipation,  retracted  abdomen, 
slow,  irregular  pulse,  Cheyne-Stokes  respiration,  and  pupillary  changes. 
Examination  of  the  fundus  and  cerebrospinal  fluid  should  be  made. 

As  abscess  of  the  brain  is  always  secondary,  there  may  be  a  history 
of  sepsis,  occasionally  rigors,  pyrexia,  leucocytosis,  and  greater  localized 
tenderness  over  the  scalp.  The  general  symptoms  of  pressure  are  less 
severe  because  an  abscess  is  a  destructive  process.  The  focal  symptoms 
are  usually  less  pronounced,  as  the  parts  involved  are  more  often  in  the 
latent  regions. 

Hydrocephalus  in  early  childhood  almost  invariably  presents  the 
characteristic  cranial  enlargement,  changes  in  the  visual  axes,  and  more 
often  apathy  without  the  intense  headaches  and  choked  disks. 

Prognosis. — The  prognosis  of  cerebral  tumor  is  exceedingly  grave, 
although  recoveries  are  reported  in  which  all  the  symptoms  of  tumor 
were  present.  There  is,  however,  always  the  possibility  of  mistaken 
diagnosis.  Syphilitic  gummata,  rare  in  infancy,  will  yield  to  proper 
exhibition  of  iodides  and  mercurials.  The  growth  may  become  quiescent 
and  life  may  continue  with  more  or  less  mental  impairment,  although 
the  tendency  of  all  intracranial  neoplasms  is  towards  a  fatal  termination, 
unless  within  the  range  of  operative  relief.  The  duration  from  the 
development  of  symptoms  may  vary  from  ten  weeks  to  ten  years.  The 
average  from  a  large  number  of  cases  in  children  is  about  two  years. 

Death  from  general  asthenia  may  occur  suddenly  from  intracranial 


ABSCESS    OF    THE    BRAIN  441 

hemorrhage,  respiratory  and  cardiac  paralysis  or  cardiac  syncope ;  or 
it  may  be  preceded  by  prolonged  coma. 

Treatment. — Medical  treatment  of  cerebral  tumor  is  not  at  all  prom- 
ising. The  routine  administration  of  full  doses  of  the  iodides  is  occa- 
sionally followed  by  a  recovery.  Palliative  treatment  is  in  order,  as 
relief  of  headaches,  nausea,  and  vomiting,  by  hypodermic  injections  of 
morphine  where  bromides  are  unavailing. 

Surgery  offers  the  only  encouragement,  and  some  prominent  surgeons 
advise  operation  whenever  brain  tumor  is  diagnosed,  except  in  syphilitic 
processes.  The  operation  is  usually  performed  in  two  stages.  In  the 
first  stage,  the  skull  lying  over  the  region  of  the  tumor  is  removed  and 
antiseptic  dressings  are  applied.  After  an  interval  of  a  week  or  so  the 
removal  of  the  growth  is  completed. 

Unfortunately,  the  cerebellum,  the  most  frequent  site  of  tumors  in 
childhood,  is  far  less  accessible  than  the  cerebrum. 

ABSCESS   OF    THE   BRAIN. 

Abscess  of  the  brain  is  considered  of  rare  occurrence  in  infancy, 
although  possibly  this  rarity  would  be  diminished  with  increased  facili- 
ties for  diagnosis  and  post-mortem  examinations.  They  are  known  to 
occur  in  early  infancy. 

Brain  abscesses  are  probably  always  secondary,  with  the  exception 
of  those  which  follow  septic  perforation  of  the  skull.  The  recognized 
causes  are  middle-ear  disease,  traumatisms  of  the  head,  caries  of  the 
cranial  bones,  and  metastasis  from  suppurative  lesions  in  any  part  of  the 
body. 

Of  all  the  causes,  middle-ear  disease  is  the  most  common.  Retention 
of  pus  is  not  necessary  for  the  extension  of  infection  from  the  tympanum 
to  the  brain.  Cases  are  reported  of  abscess  formation  after  destruction 
of  the  tympanic  membrane.  In  fact,  the  majority  of  abscesses  are 
reported  in  connection  with  suppurative  otitis  of  long  standing. 
Those  of  the  cerebellum  most  frequently  follow  mastoid  disease,  while 
tympanic  suppuration  alone  leads  more  directly  to  cerebral  abscess 
formation. 

The  white  matter  of  the  cerebrum  is  the  favorite  seat  of  abscesses, 
and  they  are  rarely  found  in  the  structures  of  the  base.  They  may  be 
single  or  multiple.  The  single  abscesses  vary  in  dimensions  from  a  few 
millimetres  to  several  centimetres,  or  they  may  involve  an  entire  lobe  and 
even  an  entire  hemisphere.  The  pus  may  perforate  the  cortex  or  break 
through  the  lateral  ventricles  and,  destroying  the  septum  lucidum.  flood 
the  entire  ventricular  area.  Subdural  abscesses  may  occur  primarily  or 
secondarily. 

All  the  common  pyogenic  organisms  have  been  found  in  the  pus  of 
cerebral  abscesses.  If  of  long  standing,  the  purulent  collection  is  fre- 
quently found  encapsulated  by  a  more  or  less  dense  membrane.  Occa- 
sionally the  limiting  membrane  is  absent,  the  walls  of  the  cavity  consist- 
ing of  irregular  masses  of  disintegrating  brain  substance. 


442  DISEASES    OF    THE    NERVOUS    SYSTEM 

An  abscess  may  remain  a  long  time  in  the  white  substance  of  the 
brain  with  the  production  of  few  or  no  symptoms. 

Naturally  the  symptoms  have  much  in  common  with  those  of  brain 
tumor,  although  less  marked,  especially  when  we  consider  their  greater 
extent  and  more  rapid  growth.  This  may  be  explained  in  part  by  their 
location  in  latent  portions  of  the  brain  and  by  the  difference  in  the 
process  of  formation,  the  tumor  increasing  by  displacement  and  con- 
densation, the  abscess  by  destructive  absorption  of  adjacent  brain  tissue. 

The  symptoms,  more  especially  of  chronic  abscess  formation,  are 
usually  recognized  as  initial,  latent,  and  terminal. 

The  initial  symptoms  may  be  masked  or  confounded  with  those  of 
the  acute  disorders  to  which  they  are  secondary.  When  recognized,  they 
may  appear  as  chill,  pyrexia,  headache,  vertigo,  vomiting,  and,  possibly, 
convulsions  followed  by  a  transient  hemiplegia.  These  symptoms  may 
continue  and  the  disease  may  run  a  more  or  less  acute  course  resembling 
sepsis,  with  leucocytosis,  rapid  emaciation,  and  prostration,  terminating 
fatally  in  ten  to  fourteen  days. 

On  the  other  hand,  the  initial  symptoms  may  subside,  the  tem- 
perature remain  normal,  and  for  weeks,  occasionally  for  months  or 
even  years,  no  symptoms  appear,  with  the  possible  exception  of  occasional 
headache,  nausea,  or  vertigo,  when,  with  a  sudden  onrush,  symptoms  of 
an  acute  meningitis  or  sudden  coma  may  terminate  the  history.  The 
post-mortem  may  reveal  rupture  of  an  encysted  abscess  through  the 
cortex  or  into  the  ventricles. 

As  the  structures  at  the  base  are  rarely  the  seat  of  abscess,  the  symp- 
toms due  to  involvement  of  the  cranial  nerves  are  not  common,  although 
optic  neuritis,  hemiopia,  and  facial  paralysis  are  occasionally  observed. 

Localized  headache  and  local  pain  or  tenderness  on  percussion  may  be 
present  when  the  abscess  is  near  the  cortex  or  extradural.  This  is  espe- 
cially true  when  the  pus  is  located  in  the  cerebellum,  in  which  case 
staggering  gait  may  be  added  to  the  general  symptoms  of  pressure. 

Diagnosis. — The  diagnosis  of  brain  abscess,  especially  in  young  chil- 
dren, is  extremely  difficult  and  is  most  frequently  made  at  the  autopsy. 
The  frequent  accompaniment  of  meningitis,  both  initial  and  terminal, 
makes  differentiation  impossible.  The  early  age  renders  valueless  most 
subjective  as  well  as  many  objective  symptoms,  so  that  motor  disturb- 
ances are  about  all  the  indications  of  value  in  diagnosis.  The  presence 
of  leucocytosis,  with  the  elimination  of  other  causative  conditions,  may 
aid  in  diagnosis,  but  the  well-known  frequency  of  leucocytosis  in  infancy 
renders  its  presence  less  significant.  The  persistence  or  frequent  recur- 
rence of  headache,  vertigo,  and  vomiting,  with  possibly  seizures  of  Jack- 
sonian  epilepsy  and  other  focal  symptoms  of  cerebral  origin,  negative 
findings  from  spinal  puncture,  with  marked  leucocytosis  not  explained 
by  suppuration  elsewhere,  may  be  taken  as  presumptive  evidence  of 
intracranial  abscess.  In  differentiation  from  brain  tumors,  their  rarity 
in  infancy  should  be  remembered.     (For  other  points  see  Brain  Tumors.) 

Treatment. — No  medical  treatment  is  of  avail  in  the  cure  of  cerebral 


HYDROCEPHALIC 


443 


abscess.  Surgery  furnishes  an  increasing  list  of  successful  operations 
for  collections  of  pus  within  the  cranium.  For  obvious  reasons  early 
operation  is  important.  Reports  show  more  than  fifty  per  cent,  of  post- 
operative recoveries. 

In  the  management  of  children,  prophylaxis  must  continue  to  be  of 
paramount  importance.  The  easy  access  to  the  brain  and  its  meninges 
for  pyogenic  bacteria  from  the  common  purulent  affections  of  the 
respiratory  and  aural  tracts  is  discussed  in  Chapter  I,  Part  I,  and  Chap- 
ter XIII,  Part  II.  The  value  of  early  attention  to  these  disorders,  as 
protective  from  the  graver  secondary  inflammations,  cannot  be  unduly 
emphasized. 


HYDROCEPHALUS — HYDROPS    CEREBRI;    WATER    ON    THE   BRAIN. 

Hydrocephalus  is  an  accumulation  of  serous  fluid  in  the  cranial  cav- 
ity. If  ventricular,  it  is  known  as  internal  hydrocephalus.  If  confined 
to  the  subdural  area  by  the  closure 
of  the  foramen  of  Magendie,  it 
is  external  hydrocephalus,  a  rare 
form.  The  excessive  accumulation 
is  usually  both  internal  and  exter- 
nal.     Hydrocephalus   is,   strictly 


Fig  154.— A  remarkable  degree  of  hy-  Fig.  155.— Congenital  enlargement  of  thyroid  gland, 

drocephalus.  (Copyrighted,  1888,  hy  Lang- 
hill,  Hanover,  N.  H.) 

speaking,  a  symptom  and  may  only  be  considered  a  disease  when  by 
excessive  pressure  it  interferes  with  functions  or  causes  atrophy  of  nerve 
or  brain  substance.  The  conditions  which  may  cause  hydrocephalus  are 
numerous  and  varied. 

The  normal  cerebrospinal  fluid  is  the  product  of  the  secretion  from 


444  DISEASES    OF    THE    NEEVOUS    SYSTEM 

the  chorioid  plexuses  which  are  most  abundant  on  the  endyma  of  the 
lateral  ventricles.  This  process  is  continuous.  The  fluid  disappears 
normally  by  absorption  through  the  lymphatic  channels  which  accom- 
pany the  nerve  sheaths  in  their  exit  through  the  pia.  In  health  the 
balance  is  thus  maintained  between  secretion  and  drainage  of  the  cerebro- 
spinal fluid.  An  excessive  accumulation  of  this  fluid  may  be  due  to 
one  or  the  other  of  three  classes  of  causes  or  to  the  three  acting  simul- 
taneously: first,  there  may  be  hypersecretion,  as  in  serous  inflammation 
of  the  meninges ;  second,  there  may  be  a  freshet  of  blood  supply  from 
vasomotor  paralysis  of  the  basilar  or  other  large  arteries;  third,  there 
may  be  transudation  of  serum  from  mechanical  stasis  due  to  cardiac  in- 
competency, pressure  on  venous  trunks  from  neoplasms,  hemorrhages 
or  exudates  or  the  occurrence  of  venous  or  sinus  thrombosis.  In  all  of 
these,  if  the  cause  be  transient,  the  excess  of  fluid  will  ultimately  be 
carried  off  by  natural  absorption. 

It  is  easy  to  see  how  basilar  meningitis,  perhaps  of  mild  type,  may 
fill  both  causative  roles  by  causing  excessive  serous  accumulation  or  by 
sealing  up  the  channels  of  outlet,  in  which  case  the  result  is  obviously 
a  dropsy  limited  only  by  the  resistance  of  the  enveloping  structure. 

The  common  classification  into  external  and  internal  hydrocephalus 
is  of  little  importance,  clinically,  except  as  an  explanation  of  the  processes 
to  which  they  are  due.  Thus,  a  mild  serous  meningitis,  in  the  course 
of  which  closure  of  Magendie's  foramen  occurs,  would  shut  off  the  com- 
munication of  the  subdural  fluid  with  the  ventricles,  the  accumulation 
thereby  remaining  external.  On  the  other  hand,  an  endymitis,  a  common 
accompaniment  of  meningitis,  with  occlusion  of  the  foramen  of  Monroe 
on  one  or  both  sides,  or  of  the  Sylvian  aqueduct,  thus  cutting  off  the 
excessive  ventricular  fluid  from  the  fourth  ventricle  with  its  facilities  for 
drainage,  would  result  in  ventricular  or  internal  hydrops. 

«  It  is  evident  that  the  most  frequent  cause  of  hydrocephalus  is  menin- 
gitis, especially  of  the  basilar  form.  It  may  be  congenital  or  acquired. 
Of  a  large  number  of  cases  developing  in  the  first  half  year  of  life,  more 
than  ten  per  cent,  showed  cranial  enlargement  at  birth.  It  is  more  than 
probable  that  a  majority  of  the  remaining  cases  were  due  to  causes  oper- 
ating in  utero,  and  not  infrequently  of  syphilitic  origin.  Infants  under 
two  years  show  the  greatest  susceptibility,  inversely  as  to  age,  although 
acquired  hydrocephalus  is  occasionally  seen  in  older  children  and  even 
in  adults. 

The  disease  is  essentially  chronic,  although  acute  attacks  are  not 
uncommon  and  as  such  are  closely  allied  to  tuberculous  meningitis,  with 
which  the  term  is  frequently  synonymous. 

Symptoms. — The  symptoms  of  hydrocephalus  are  similar  to  those  of 
meningitis,  so  far  as  they  relate  to  pressure  as  a  cause.  Usually  the  first 
evidence  of  hydrocephalus  is  the  abnormally  large  head,  which  may 
measure  at  birth,  or  a  few  days  after,  forty  to  forty-six  centimetres. 
When  the  accumulation  of  fluid  occurs  before  birth,  the  large  head 
may   prove   such   an   obstacle   in   parturition   that   destruction   of   the 


HYDROCEPHALUS  145 

infant  is  necessary  to  effect  delivery.  An  infant,  apparently  normal 
at  birth,  may  show  this  enlargement  in  the  early  mouths,  with  or 
"without  precedent  convulsions.  The  fontanel  Lea  bulge  under  the  tense, 
shiny  scalp ;  the  sutures  may  be  widely  separated ;  the  hair  becomes 
scanty  from  atrophy  of  the  follicles  due  to  tension  of  the  scalp.  The 
pressure  from  within  causes  congestion  of  the  collateral  circulation,  so 
that  the  superficial  veins  are  full  and  tortuous. 

The  head  may  assume  a  globular  form  with  dome-like  vertex,  or 
there  may  be  occipital  and  frontal  bulging.  Lateral  asymmetry  is  com- 
mon. There  is  a  marked  fulness  at  the  root  of  the  nose  and  the  skin  of 
the  eyelids  is  stretched.  The  sclerotics  show  above  the  irides  because  of 
the  downward  inclination  of  the  visual  axes  from  pressure  upon  the 
supraorbital  plates. 

Even  in  older  infants  the  weak  neck  fails  to  sustain  the  enlarged 
head,  which  rolls  helplessly  from  side  to  side  or  falls  forward  against  the 
chest.  The  entire  muscular  system  is  weak  and  flabby,  although  occa- 
sionally the  infant  shows  considerable  deposit  of  adipose.  Even  older 
children  are  unable  to  stand  or  sit  alone  because  of  the  muscular  atony. 
Occasionally  plegias  of  spastic  type  with  subsequent  contractures  are 
seen.  Appetite  and  digestion  are  astonishingly  good  in  the  majority  of 
cases.  The  special  senses  are  rarely  affected.  Hemiopia  occasionally 
is  seen,  and  rarely  amblyopia.  Converging  strabismus  is  common,  and 
nystagmus  is  occasionally  present. 

The  infant  suffers  little  or  no  pain,  is  usually  apathetic,  but  exhibits 
more  intelligence  than  would  be  thought  possible  from  the  evidence  of 
enormous  intracranial  pressure.  The  face,  frequently  described  as 
weazened,  is  probably  proportionate  to  the  undeveloped  body.  The  ver- 
tical, longitudinal  and  lateral  expansion  of  the  cranium  makes  the 
face  appear  insignificant.  The  head  as  a  whole  presents  an  inverted 
pyramidal  shape.  Acquired  hydrocephalus,  after  complete  ossification, 
does  not  usually  show  the  marked  enlargement  of  the  head,  although 
the  sutures  may  yield,  even  after  bony  union,  to  the  great  pressure  from 
within. 

Lesions. — Post-mortem  examination  reveals  but  little  resemblance  to 
normal  encephalic  structures.  The  convolutions  of  the  convexity  have 
disappeared.  The  membranes  of  the  convexity  may  show  little  evidence 
of  inflammatory  changes.  At  the  base  they  are  often  somewhat  thickened 
and  opaque.  The  ventricular  ependyma  is  thickened,  its  blood-vessels 
distended,-  and  its  surface  roughened.  Differentiation  between  gray  and 
white  matter  is  impossible.  The  cortical  substance  may  be  extremely 
attenuated  from  the  distention  of  the  lateral  ventricles.  These  appear 
like  large  bags  containing  fluid,  from  one  to  several  pints  in  amount. 
This  fluid  is  clear,  colorless,  slightly  alkaline,  and  contains  chlorides  of 
potassium  and  sodium  and  alkaline  phosphates.  Occasionally  globulin, 
albuminose,  peptone,  and,  rarely,  a  trace  of  albumin,  are  found ;  also  a 
copper-reducing  agent  formerly  supposed  to  be  sugar.  The  specific 
gravity  ranges  from  1.003  to  1.009.     The  denser  fluid  shows  turbidity 


446  DISEASES    OF    THE    NERVOUS    SYSTEM 

from  inflammatory  products.  In  extreme  cases  the  meninges  and  cere- 
bral tissue  are  compressed  into  one  apparent  membrane  less  than  a 
millimetre  in  thickness.  A  matter  of  constant  surprise  is  the  persistence 
of  function,  or  even  life,  with  such  extensive  destruction  of  cerebral 
substance. 

The  changes  in  the  bones  of  the  skull  are  not  constant  and  appear  in 
those  of  the  vault  rather  than  at  the  base.  Thinning  is  sometimes  plainly 
evident,  the  diploe  having  been  quite  obliterated  in  some  parts.  The 
structures  of  the  cerebellum  and  pons  frequently  show  pressure  effects 
and  retardation  in  development.  Developmental  defects,  such  as  poren- 
cephaly, spina  bifida,  meningocele,  cleft  palate,  hypospadias,  etc.,  are 
associated  with  congenital  hydrocephalus  with  sufficient  frequency  to 
attract  more  than  passing  attention.  Brain  tumors  may  be  found  which 
bear  an  undoubted  relationship  to  the  dropsy. 

Prognosis. — Congenital  hydrocephalics  rarely  outlive  the  second  year. 
Occasionally  a  condition  of  helpless  idiocy  is  prolonged  for  four  or  five 
years.  They  usually  succumb  to  marasmus  or,  having  feeble  resistance, 
fall  victims  to  some  trifling  intercurrent  affection. 

Acquired  hydrocephalus  is  influenced  in  its  duration  and  termination 
by  the  nature  of  the  primary  disease  to  which  it  is  due.  A  considerable 
degree  of  cranial  enlargement  and  mental  impairment  is  not  incom- 
patible with  prolongation  of  life  to  the  adult  period.  Occasionally  the 
rapid  cranial  expansion  slackens  while  the  increased  body  growth  renders 
the  discrepancy  less  marked.  There  is  a  gradual  disappearance  of  press- 
ure symptoms  with  apparent  recovery  in  all  the  functions.  The  general 
enlargement  of  the  head,  however,  remains  as  evidence  of  the  early  hydro- 
cephalus. Complete  recoveries  from  an  extreme  degree  of  cerebral  hy- 
drops are  rare.  The  usual  course,  which  may  continue  for  years,  is 
marked  by  periods  of  apparent  improvement  alternating  with  exacer- 
bations of  pressure  symptoms. 

Paralyses  and  spasticity  usually  mark  the  victim  of  this  chronic 
type,  and  mental  impairment  of  varying  degree  is  the  general  rule,  until 
intercurrent  disease  or  acute  convulsions  terminate  life. 

Diagnosis. — Hydrocephalus  is  diagnosed  by  the  abnormal  increase 
in  the  size  of  the  head.  Its  other  symptoms  are  common  to  cerebral  irri- 
tation and  intracranial  pressure  from  any  cause.  Since  the  head  of  a 
normal  baby  at  birth  averages  thirteen  and  one-half  inches  (34  Cm.), 
at  six  months  seventeen  inches  (43  Cm.),  at  one  year  eighteen  inches 
(46  Cm.),  and  at  two  years  twenty  inches  (51  Cm.)  in  circumference, 
any  marked  excess  over  these  figures  would  constitute  an  enlargement. 
The  ordinary  rapidity  of  increase  should  be  determined  by  repeated 
measurements  at  regular  intervals.  This  head  enlargement,  in  con- 
junction with  a  history  of  the  before-mentioned  symptoms,  should 
render  the  diagnosis  plain. 

Other  causes  of  head  enlargement,  such  as  bony  hypertrophy  from 
rhachitis  and  syphilis,  should  show,  in  the  history  or  on  physical  examina- 
tion, other  evidences  of  those  dyscrasiae.     The  rhachitic  head  lacks  the 


CEREBRAL    PALSIES  447 

globular  character  of  hydrocephalus,  is  more  angular  on  account  of  the 
parietal  ridges,  and  presents  bossse  with  intervening  depressions  or  plain 
areas.  The  intellectual  precocity  of  the  rhachitic  is  in  marked  contrast 
to  the  impaired  mentality  of  the  hydrocephalic.  The  syphilitic  head 
gives  evidence  of  cranial  thickness  from  bony  overgrowth.  In  both 
forms  of  enlargement  the  pressure  symptoms  characteristic  of  hydro- 
cephaly are  wanting. 

In  regard  to  size,  however,  it  must  be  remembered  that  premature 
ossification  with  resulting  microcephaly  may  mask  the  commonest  sign 
of  hydrocephalus.  In  these  cases  of  microcephalic  hydropsia  the  positive 
diagnosis  is  only  made  post-mortem. 

Treatment. — Congenital  hydrocephalus  yields  to  no  treatment.  Since 
cases  of  the  acquired  form  have  been  known  to  recover,  it  is  probably 
wise  to  attempt  the  amelioration  of  pressure  symptoms  by  all  possible 
means.  During  an  exacerbation  of  acute  symptoms,  withdrawal  of  fluid 
by  repeated  lumbar  punctures  in  cases  where  the  communication  is  unin- 
terrupted is  worthy  of  trial.  If  unsuccessful,  the  ventricles  may  be 
aspirated  with  due  aseptic  caution,  care  being  taken  to  avoid  the  longi- 
tudinal sinus. 

The  fact  that  syphilis  is  responsible  for  a  certain  proportion  of  cases 
warrants  the  exhibition  of  iodides  and  mercurials. 

Various  surgical  procedures  for  drainage  are  still  attempted  with 
encouraging  results  in  but  a  small  number  of  cases.  It  is  believed  by 
some  surgeons  that  a  method  of  drainage  will  ultimately  be  devised 
which  will  maintain  intra-  and  extra-vascular  equilibrium.  It  must  be 
borne  in  mind,  however,  that  the  primary  cause  of  fluid  accumulation 
may  also  be  responsible  for  many  of  the  symptoms  attributed  to  the 
pressure  of  the  fluid. 

INFANTILE    CEREBRAL    PALSIES — SPASTIC    HEMIPLEGIA;      DIPLEGIA;     PARA- 
PLEGIA. 

For  clinical  convenience,  the  cerebral  palsies  are  divided,  according 
to  the  time  of  occurrence  of  the  cerebral  lesion,  into  three  classes, — pre- 
natal, natal,  and  postnatal. 

These  disorders  are  very  common  during  the  first  decade  of  life,  as 
the  records  of  any  children's  clinic  will  attest.  The  onset  of  the  disease 
in  more  than  eighty-five  per  cent,  of  the  cases  occurs  before  the  end  of 
the  third  year.  Infantile  cerebral  palsies  include  all  plegias  of  cerebral 
origin  from  lesions  (not  absolutely  determinate,  like  encephalic  tumor, 
abscess,  or  dropsy)  which  cause  contractures,  rigidity,  choreiform,  and 
athetoid  movements  or  mental  impairment. 

Prenatal  paralyses  are  due  to  some  defects  in  cerebral  development, 
as  porencephaly  (in  which  a  greater  or  less  portion  of  the  brain  is 
wanting)  or  "agnesis  corticalis"  (arrested  or  defective  development  of 
the  cortical  and  pyramidal  cells),  or  possibly  to  intracranial  hemor- 
rhages occurring  during  the  latter  period  of  gestation.  The  causes  are 
variously  attributed  to  neurotic  family  history,  traumatism  to  mother 


448 


DISEASES    OF    THE    NERVOUS    SYSTEM 


or  child,  as  by  blows  or  falls,  also  to  shock,  fright,  convulsions,  or  illness 
of  the  mother.  The  child  at  birth  may  show  loss  of  power,  spastic 
flexures,  or  rigidity  of  one  or'  more  of  the  extremities,  with  later  evi- 
dences of  mental  impairment  which  may  amount  to  idiocy.  Fortunately 
many  of  these  defective  children  die  early  of  inherent  weakness  or  from 
inability  to  nurse. 

Natal  Paralysis  (birth  palsies). — These  are  probably  due,  in  the  ma- 
jority of  instances,  to  meningeal  hemorrhages,  asphyxia  neonatorum, 
prolonged  and  premature  labors,  and  rarely  to  the  use  of  forceps.     The 

early  and  skilful  use  of  instruments 
would,  no  doubt,  prevent  this  acci- 
dent in  many  instances.  The  greater 
frequency  of  birth  palsy  in  the  first 
child  of  a  family  is  suggestive  of  their 
etiology. 

Among  the  lesions  reported  are 
meningoencephalitis  (Fig.  156),  fol- 
lowed by  thickening  and  adhesion  of 
the  pia  mater,  with  cellular  prolifera- 
tion in  the  walls  of  the  blood-vessels, 
obliteration  of  the  pyramidal  cells  of 
the  cortex  and  degeneration  in  the  py- 
ramidal tracts.  Sclerotic  changes  may 
occur  with  atrophy  more  or  less  ex- 
tensive, occasionally  involving  large 
portions  of  one  or  both  hemispheres. 
Cysts  may  develop  and  secondary  de- 
generation in  the  lateral  columns  of 
the  cord  follow  the  extensive  atrophy 
and  sclerosis. 

The  immediate  or  primary  symp- 
toms usually  indicate  the  extent  of 
the  hemorrhage.  If  this  be  wide- 
spread, convulsions  occur.  Para- 
plegia or  diplegia  develop  early,  and 
coma  may  follow,  with  danger  of 
death.  If  the  baby  survive  the  at- 
tack, the  secondary  symptoms  will 
depend  largely  upon  the  amount  and 
distribution  of  the  hemorrhage  and 
the  secondary  lesions  which  develop. 
In  paralysis  of  antenatal  origin 
the  majority  of  palsies  are  para-  or  diplegic.  In  this  class  the  mortality 
in  severe  cases  is  fortunately  high,  since  the  certainty  of  physical  help- 
lessness and  mental  deficiency  makes  early  death  a  boon  to  be  desired 
(Figs.  159-161). 

Infants  surviving  the  less  extensive  injuries  may  exhibit  only  slight 


Fig.  156.— Infant,  3  days  old.  Forceps  de- 
livery. Hemorrhage  into  the  perieto-oceip- 
ital  and  calcarine  fissures,  with  softening  of 
the  surrounding  cortex.    (Dr.  P.  Bassoe.) 


CEREBRAL    PALSIES 


■449 


rigidity  or  spastic  involvement  of  the  legs,  or  occasionally  only  one  limb 
(monoplegia)  may  show  this  symptom  and  is  often  overlooked.  It  often 
happens  that  no  symptoms  are  observed  by  the  parent  and  no  history 
of  convulsions  is  given,  the  physician  being  consulted  because  of  the 
child's  physical  and  mental  "backwardness."  There  may  be  a  tendency 
to  head  retraction,  to  strabismus,  or  the  legs  may  be  weak  and  the  neck 
limber,  suggestive  of  rhachitis.  Interrogation  may  bring  out  the  fact 
of  a  prolonged,  difficult,  or  premature  labor,  delayed  forceps  delivery, 
or  asphyxiation.  Examination  may  show  slight  spasticity  and  exag- 
gerated knee-jerk.  The  child  may  learn  to  walk  late,  possibly  in  the 
third  year,  but  the  gait  is  unsteady,  there  is  a  tendency  to  crosslegged 


Fig.  157.— Birth  palsy.  Aged  4  years.  Micro- 
cephalic idiot;  strabismus,  facial  asymmetry, 
right  hemiplegia. 


Fig.  158.— Cerebral  palsy  (natal).  Aged  10 
years.  Microcephalous,  strabismus,  ptosis, 
facial  paresis,  slight  contractures  and  spas- 
ticity, exaggerated  reflexes,  choreic,  athe- 
toid,  and  associated  movements;  very  slight 
mental  impairment. 


progression,  and  the  feet  turn  under.  The  child  may  be  microcephalic 
or  show  cranial  or  facial  asymmetry  with  gothic  palate  and  other  degen- 
erative stigmata  (Fig.  157).  Convulsions  may  have  occurred  and  borne 
the  responsibility  for  the  maldevelopment  of  shortened  limb  and  de- 
fective mind,  which  are  really  due  to  the  birth  injury  and  the  progressive 
central  changes  incident  thereto.  Athetoid  movements  in  one  or  more 
members,  usually  the  hand,  or  mild  localized  chorea  (Fig.  158),  may  lead 
the  physician  to  suspect  the  true   lesion.     Epilepsy  is  very  common, 

29 


450 


DISEASES    OF    THE    NERVOUS    SYSTEM 


usually  beginning  as  the  Jacksonian  type  in  the  most  affected  limb,  and 
later  becoming  general. 

Postnatal  Palsies  (acute  acquired  cerebral  paralysis). — Most  of  these 
cases  occur  before  the  fifth  year  and  nearly  half  during  the  second  year 
of  life.  The  paresis  characteristic  of  this  form  is  of  the  hemiplegic 
variety.  Although  double  hemiplegia  and  apparent  monoplegia  of  an 
upper  limb  are  occasionally  seen,  paraplegia  is  rare. 

Among  the  causes  usually  ascribed  are  the  infectious  fevers,  pneu- 
monia, pertussis,  shock,  traumatism,  and  convulsions.  The  tissues  in- 
volved in  the  causative  lesions  may  be  the  blood-vessels,  the  meninges,  or 
the  brain  itself. 

Undoubtedly  the  majority  of  attacks  are  the  direct  or  remote  result 
of  meningeal  hemorrhages  which,  because  of  faulty  development  of  the 


Fig.  159.— Aged  10  years.    Prenatal  form  of  cerebral  palsy.    Diplegia  idiot,  with  spasticity. 


vessel  walls,  are  readily  induced  during  any  of  the  acute  infections  and 
when  the  blood-pressure  is  unduly  raised  from  any  cause,  as  in  par- 
oxysms of  coughing,  in  pertussis,  pneumonia,  in  cardiac  disease,  etc. 
More  especially  is  this  true  of  severe  or  prolonged  convulsive  seizures, 
although  undoubtedly  the  etiologic  relationship  of  convulsions  and  cere- 
bral lesions  may  be  reciprocal.  In  all  forms  of  cerebral  palsy  embolism 
and  sinus  thrombosis  may  prove  to  be  the  exciting  cause  due  to  endo- 
carditis, arteritis,  or  venous  stasis,  however  induced.  The  postnatal 
palsies  are  called  "acquired"  or  "acute"  because  due  to  causes  not 
operative  before  birth  (although  this  is  questionable),  and  because  the 
onset  is  acute.  In  this  respect  there  is  resemblance  to  acute  spinal 
paralysis    (acute  poliomyelitis  anterior)    and  this,  with  other  clinical 


CEREBRAL    PALSIES  451 

similarities,  has  led  some  eminent  observers  to  regard  acute  polioenceph- 
alitis as  a  frequent  etiologic  lesion.  However  interesting  the  clinical 
analogy,  recent  post-mortem  findings  do  not  bear  out  this  theory. 

Pachymeningitis,  or  meningoencephalitis  resulting  from  previous  in- 
flammations or  from  syphilis  and  occasionally  tubercles,  may  be  a 
primary  lesion,  but  whatever  may  be  the  original  cause,  whether  in- 
fective, mechanical,  or  both,  the  secondary  changes  in  the  brain  substance 
and  upper  cord  are  of  the  greatest  importance,  for  by  them  the  vicious 
circle  is  perpetuated,  with  resultant  permanent  impairment  of  function, 
both  mental  and  motor. 

Among  the  terminal  brain  lesions  there  may  be,  as  in  the  natal 
variety,  cysts,  atrophy,  and  sclerosis  of  the  brain  substance,  more  or 
less  extensive,  with  descending  degeneration  into  the  spinal  cord. 

The  onset  of  postnatal  cerebral  paralysis  is  sudden  and  is  preceded 
by  convulsions  in  more  than  half  the  cases.  Febrile  symptoms  are  fre- 
quently pronounced  and  there  may  be  vomiting.  The  convulsions  may 
be  repeated  at  short  intervals  and  coma  often  ensues.     Speech  may  be 


Fig.  100. — Spastic  contractures  in  diplegia. 

affected,  especially  with  left  cerebral  lesions,  and  the  mind  is  impaired. 
After  the  acute  symptoms  have  subsided  the  paralysis  is  evident  and 
may  rarely  involve  the  face,  although  strabismus  is  common.  The  com- 
monest type  is  hemiplegia,  at  first  usually  quite  complete,  and  sensation 
may  be  temporarily  abolished,  while  the  deep  reflexes  are  exaggerated  on 
the  affected  side.  Later,  sensation  returns  and  motion  is  frequently  re- 
stored to  the  affected  limb,  although  rarely  completely.  Spasticity  grad- 
ually asserts  itself  and,  in  time,  contractures  follow  (Fig.  160),  while  the 
tendon  jerk  and  ankle  clonus  remain  a  persistent  feature.  Occasionally 
slight  evidence  of  the  paralysis  may  remain,  except  postplegic  athe- 
toid  or  choreic  movements.  Spasticity  of  the  limbs  may  always  be 
detected  upon  careful  examination.  In  half  the  cases  eclamptic  seizures 
recur,  and  confirmed  epilepsy  is  the  result,  usually  focal  in  character 
at  the  beginning.  Convulsions  may  be  wanting,  the  child  awakening 
with  hemiplegia  after  retiring  in  apparent  health.  This  onset  is  very 
similar  to  that  occasionally  seen  in  acute  spinal  paralysis.     The  face, 


452  DISEASES    OF    THE    NERVOUS    SYSTEM 

when  involved,  usually  recovers  early.  Paralysis  of  the  ocular  muscles 
frequently  persists,  with  resulting  strabismus.  Permanent  aphasia, 
both  motor  and  intellectual,  is  common, — the  younger  the  child  the  more 
frequently  do  speech  defects  follow  right  cerebral  lesions.  Exaggerated 
deep  reflexes  may  be  found  in  the  opposite  as  well  as  in  the  paretic 
limb.  They  are  normal,  lessened,  or  absent,  in  about  five  per  cent,  of 
the  cases,  although  rigid  contractures  may  prevent  their  elicitation. 
Athetoid,  choreic,  and  associated  movements  are  common,  also  rhythmic 
contractions,  tremors,  and  nystagmus. 

Rigidity  and  contractures  are  the  characteristic  features  of  all  cere- 
bral palsies.  The  arm  is  flexed  and  pronated  with  extreme  flexion  of 
wrist,  hand,  and  fingers,  with  strong  adduction  to  the  side.  The  knee 
and  thigh  may  be  flexed  more  or  less,  and  the  foot  shows  talipes  equinus 
or  equinovarus.  The  adductors  of  the  thigh  are  contracted  so  that 
cross-legged  locomotion  is  the  rule,  while  the  rigid  contractures  limit 


Fig.  161. — Aged  10  years.    Prenatal  form  of  cerebral  palsy.    Microcephalic,  strabismus,  diplegic, 
spasticity  and  contractures. 

the  movements  (Fig.  161).  If  able  to  walk,  the  gait  is  spastic,  jerky, 
and  springy  in  character. 

There  is  atrophy  of  the  muscles  from  disuse  and  retarded  growth,  so 
that  after  a  time  the  entire  limb  may  be  smaller  and  shorter  than  its 
unaffected  mate. 

Mind  impairment  and  idiocy  are  in  direct  ratio  to  the  extent  of  the 
cerebral  lesion,  the  paraplegics  and  diplegics  showing  the  greater  defi- 
ciency. In  hemiplegics  mental  defects  are  less  common  and  severe. 
Taken  altogether,  half  the  cerebral  palsies  show  mental  impairment 
while  other  stigmata  of  degeneration  are  common, — as  cranial  asym- 
metry, high  palate,  abnormal  ears,  hairy  skin,  etc. 

Prognosis. — It  is  not  possible  to  predict  the  extent  of  damage  at  the 
beginning  of  the  attack.  Children  suffering  from  diplegia  and  para- 
plegia usually  die,  before  the  end  of  the  second  year,  of  some  intercurrent 
disease.  The  unfortunates  who  survive  for  a  longer  period  lead  a  purely 
vegetative  existence,  being  helpless  and  hopeless  idiots  (Figs.  159-i61). 
In  the  cases  of  hemiplegia,  the  prognosis  is  not  so  grave,  although  an 


PROGRESSIVE  BULBAR  PARALYSIS        453 

entire  recovery  cannot  be  expected.  The  face  and  leg  regain  power  earlier 
and  to  a  greater  extent  than  does  the  arm.  Speech  may  be  delayed  for 
weeks  or  months,  but  in  young  children  is  fully  recovered.  Epilepsy, 
which  may  appear  a  year  or  more  after  the  paralysis,  renders  the  prospect 
of  normal  mental  development  unfavorable.  All  the  possibilities  should 
be  carefully  explained  to  the  parents. 

Diagnosis. — The  diagnostic  points  are  paralysis  (paraplegia,  diplegia, 
hemiplegia,  and  rarely  monoplegia)  more  or  less  complete  with  rigidity 
or  spasticity,  with  possibly  unilateral  choreic  or  athetoid  movements. 
No  early  atrophy  or  change  in  electrical  reaction  is  present.  The  tendon 
reflexes  with  clonus  are  increased  in  nearly  all  cases.  Mental  impair- 
ment occurs  in  fifty  per  cent,  of  cases  and  recurrent  convulsions  in  the 
same  proportion.  Rarely  a  spinal  palsy  may  develop  in  an  old  cerebral 
hemiplegia  and  furnish  symptoms  of  both.  Well-marked  cases  of  infan- 
tile cerebral  palsy  are  not  difficult  to  diagnosticate,  but  those  of  slighter 
degree,  affecting  only  one  extremity,  may  suggest  a  spinal  lesion.  Infan- 
tile spinal  palsy  selects  usually  groups  of  muscles  rarely  involving  an 
entire  limb;  the  tendon  reflexes  are  absent;  the  paralysis  is  flaccid; 
the  wasting  is  rapid  and  marked ;  the  reaction  of  degeneration  is  present, 
and  there  is  no  impairment  of  the  mind.  In  a  paralysis  due  to  neuritis, 
there  is  no  rigidity  or  imbecility,  and  there  is  the  changed  electrical  reac- 
tion. A  paraplegia  due  to  caries  of  the  spine  would  show  the  angular 
deformity  of  the  vertebras  and  an  absence  of  mental  weakness  or  epilepsy. 

Treatment. — Special  education,  if  begun  early,  may  do  much  for  the 
mentally  defective.  This  is  especially  true  in  the  cases  of  hemiplegia,  as 
there  is  the  possibility  of  one  hemisphere  escaping  damage.  Massage  and 
electricity  are  of  value  in  keeping  up  the  nutrition  of  the  muscles  and  in 
arresting  the  deformities.  Orthopaedic  surgery  may  relieve,  to  a  certain 
extent,  the  contractures  and  allow  locomotion. 

PROGRESSIVE  BULBAR  PARALYSIS LABIOGLOSSOLARYNGEAL  PARALYSIS. 

Closely  allied  to  the  amyotrophic  palsies  is  progressive  bulbar  paraly- 
sis. Although  bulbar  symptoms  may  be  present  in  a  great  variety  of 
pathological  processes,  as  tabes,  multiple  sclerosis,  lateral  sclerosis,  polio- 
encephalitis, hemorrhages,  tumors,  etc.,  reference  is  here  made  to  a  dis- 
tinct form  of  bulbar  lesion  which,  by  giving  rise  to  certain  common 
definite  symptoms,  renders  the  ante-mortem  diagnosis  possible. 

The  disease  is  rare  at  any  period  of  life  but  is  seen  in  childhood  with 
sufficient  frequency  to  warrant  its  mention.  The  etiology  is  obscure 
both  as  to  predisposing  and  exciting  causes. 

The  first  symptom  to  attract  attention  is  usually  a  speech  defect,  as 
indistinct  enunciation  of  certain  sounds ;  or  possibly  difficulty  in  deglu- 
tition, which  gives  rise  to  coughing  and  strangling  while  eating.  The 
physician  may  not  see  the  case  until  after  the  development  of  a  classical 
group  of  symptoms,  known  as  labioglossolaryngeal  or  pharyngeal  paraly- 
sis. These  point  strongly  to  the  medulla  as  the  site  of  lesion  (Fig.  162), 
the  primary  character  of  which  is  determined  by  the  exclusion  of  all  other 


454 


DISEASES    OF    THE    NERVOUS    SYSTEM 


known  processes.     The  child  may  appear  normal  in  every  respect,  aside 
from  the  following  group  of  symptoms. 

Although  usually  somewhat  emotional,  laughing  and  crying  at  the 
same  time,  the  face  shows  the  absence  of  the  usual  orolabial  participation 
in  the  expression  (Fig.  163).  The  nether  lip  is  pendulous,  with  the 
suggestion  of  tapir-mouth,  from  which  the  saliva  drools  and  to  which 
during  mastication  the  hand  is  frequently  applied  to  assist  in  the  reten- 
tion of  food.  The  appearance  of  the  tongue  is  characteristic,  as  it  lies 
obviously  atrophied  in  the  floor  of  the  mouth.  It  is  usually  furred, 
markedly  fissured,  and  shows  fibrillary  tremors.  The  child  may  be 
unable  to  protrude  the  tongue  beyond  the  teeth  or  approximate  its  tip 
to  the  roof  of  the  mouth.  The  voice  is  weak  and  nasal  in  quality.  The 
dental-labial  consonants  are  imperfectly  enunciated  from  paresis  of 
tongue  and  lips.    For  the  same  reason  the  child  cannot  whistle  or  purse 


v*' 


r  ** 


-9 
*9      '*> 


Fig.  162.  — Round-celled  infiltration  around  a 
blood-vessel  in  the  medulla  in  case  of  bulbar 
paralysis.    Shown  in  Fig.  163.     (Dr.  P.  Bassoe.) 


Fig.  163. — Progressive  bulbar  paralysis. 
Aged  11  years.  Death  7  months  after  first 
appearance  of  symptoms. 


the  mouth.  Fluids  may  regurgitate  through  the  nose  in  swallowing, 
while  choking  and  coughing  may  result  from  particles  entering  the 
unguarded  larynx.  Tactile  sensation  and  the  special  senses  are  not 
involved,  with  the  occasional  exception  of  taste  near  the  tip  of  the 
tongue.  As  an  occasional  accompaniment,  paralysis  of  the  upper  part 
of  the  face,  with  lagophthalmos  and  ptosis,  occurs. 

In  the  early  part  of  the  disease  the  muscles,  with  the  exception  of.  the 
tongue,  show  no  atrophy  or  change  in  electrical  reaction.  Later  on, 
however,  wasting  and  the  reaction  of  degeneration  are  found  in  all  the 
muscles  involved. 

As  the  disease  progresses,  the  heart  action  becomes  rapid  and  irregu- 
lar, respiration  shallow  and  easily  disturbed,  and  attacks  of  angina  dis- 
tress the  child.     The  general  weakness  of  the  muscular  system  is  due  in 


IDIOCY  455 

part  to  the  insufficient  food  supply  from  imperfect  mastication  and 
difficult  deglutition.  Bronchial  and  pneumonic  complications  are  com- 
mon from  aspiration  of  particles  of  food  and  secretions.  The  child 
becomes  irritable,  morose,  and  peevish. 

Prognosis. — Some  intercurrent  disease,  as  pneumonia,  often  termi- 
nates the  history  in  anticipation  of  the  progressive  asthenia. 

Diagnosis. — True  bulbar  paralysis  is  diagnosed  from  other  diseases 
having  bulbar  symptoms  by  the  history  and  the  several  characteristic 
symptoms  of  these  diseases. 

Myasthenia  gravis,  or  pseudobulbar  paralysis,  is  a  term  applied  to  a 
similar  group  of  symptoms  in  which,  however,  no  bulbar  lesion  exists. 
With  care  it  may  be  differentiated  from  true  bulbar  paralysis  by  the  fact 
that  the  pseudo-labioglossopharyngeal  paresis  always  follows  upon  the 
use  of  the  muscles  involved,  disappearing  after  an  interval  of  rest.  In 
the  same  way  electrical  response  disappears  after  repeated  faradization, 
to  reappear  after  a  period  of  discontinuance. 

This  temporary  paresis  of  exhaustion  is  of  interest  in  connection  with 
convalescence  from  any  severe  illness  in  children.  In  them  the  weak 
nasal  voice,  dysarthria,  and  dysphagia  are  evident  to  a  mild  degree,  but 
disappear  with  full  return  of  strength. 

Treatment. — Progressive  bulbar  paralysis,  from  the  nature  of  its 
pathology,  is  not  amenable  to  treatment.  The  pseudo  form  is  best  treated 
by  absolute  rest,  accompanied  by  forced  feeding  of  concentrated  and 
easily  digestible  articles  of  diet.  Gavage  is  employed,  not  only  on  ac- 
count of  the  dysphagia  but  to  secure  rest  for  the  muscles  involved  in 
mastication  and  deglutition.    Electricity  should  not  be  employed. 

IDIOCY — IMBECILITY   AND   FEEBLE-MINDEDNESS. 

Idiocy,  imbecility,  and  feeble-mindedness  are  too  frequently  among 
the  penalties  of  civilization.  The  variations  in  degree  of  mental  devel- 
opment are  endless,  and  numerous  arbitrary  classifications  have  been 
made. 

The  answer  to  the  query  of  the  anxious  parent  as  to  the  prognosis 
regarding  the  mentally  defective  child  depends  so  largely  upon  the 
cause  and  nature  of  the  defect  that  the  following  simple  classification  is 
suggested : 

First,  as  to  cause :  A,  heredity ;  B,  accident.  To  Class  A  belong  the 
children  of  mentally  defective  progenitors  who  are  neurotic, — such  as 
epileptics,  insane,  hysterical,  highly  emotional,  alcoholic,  syphilitic, 
tuberculous,  and  blood-related. 

Second,  as  to  time  of  commencement:  A,  antenatal;  B,  at  birth; 
C,  postnatal. 

v  Accidental  causes  are  those  which  operate  in  such  a  way  as  to  arrest 
the  growth  of  the  brain  or  to  destroy  its  function  by  the  production  of 
pathological  lesions.  The  first  class  follows  the  law  of  nature  that 
perfect  fruit  cannot  spring  from  degenerate  seed.  The  second,  that 
interference  with  the  growth  of  an  organ  during  its  period  of  develop- 


456  DISEASES    OF    THE    NERVOUS    SYSTEM 

ment  may  not  only  arrest  the  growth,  but  will  pervert  its  function.  The 
growth  of  the  brain  is  practically  complete  by  the  eighth  year.  The 
period  of  most  rapid  postnatal  growth  is  the  first  two  years,  at  which 
time  this  organ  more  than  trebles  its  birth  weight.  The  intrauterine 
period,  however,  shows  the  greatest  activity,  as  in  addition  to  its  remark- 
able increase  in  weight,  cell  multiplication  is  completed  before  birth. 

Among  the  accidents  which  arrest  or  pervert  brain  growth,  the  com- 
monest are  intracranial  hemorrhage  and  meningitis.  These  by  the  press- 
ure of  effused  blood  or  inflammatory  exudate  so  interfere  with  the  nutri- 
tion of  the  brain  tissue  that  normal  growth  is  prevented.  Other  in- 
fluences undoubtedly  operate  to  disturb  the  nutrition  of  the  brain  by 
impoverishing  its  blood  supply  or  interfering  with  its  circulation.  In- 
fections, disturbances  of  trophic  innervation,  extremes  of  temperature, 
physical  and  psychical  shock,  are  mentioned  among  the  possible  causes 
of  brain  accident.  Both  heredity,  as  predisposing  cause,  and  accidental 
lesion  as  determining  cause  of  mental  defect,  may  operate  in  the  same 
individual.  Congenital  idiocy  may  be  due  to  either  cause,  as  undoubt- 
edly the  accidents  and  contingencies  of  gestation  are  responsible  for 
idiocy  in  children  of  healthy  parentage.  Both  meningitis  and  hemor- 
rhage are  known  to  occur  in  utero,  while  examples  of  prenatal  arrested 
or  perverted  brain  growth  are  seen  in  congenital  porencephaly,  micro- 
cephaly, hydrocephaly,  and  asymmetry.  Instances  are  numerous  in 
which  injuries  to  the  mother  from  falls,  blows,  or  shocks,  also  emotional 
disturbances,  excessive  coitus,  hemorrhages,  severe  sickness,  or  general 
impairment  of  health,  have  preceded  the  birth  of  idiotic  children. 

It  has  been  shown  that  over  fifty  per  cent,  of  idiocy  is  congenital.  Of 
these  about  ninety  per  cent,  showed  histories  of  hereditary  predisposi- 
tion. Among  the  same  children  birth  accidents,  premature  delivery,  and 
difficult  labor  occurred  in  more  than  twenty-one  per  cent.  Competent 
observers  have  noted  as  a  cause  prolonged  labor  in  about  thirty  per 
cent,  of  all  idiotic  children.  The  preponderance  of  male  idiots  is. 
suggestive  of  the  greater  liability  of  the  larger  heads  to  parturition 
injuries. 

The  number  of  cases  of  acquired  idiocy,  resulting  from  injuries  or 
brain  lesions  occurring  after  birth,  is  probably  less  than  the  congenitally 
defective,  though  the  percentage  of  cases  assigned  to  postnatal  influences 
appears  greater.  Hereditary  influences  and  morbid  antenatal  conditions 
may  exist  in  earliest  infancy  without  evidences  of  brain  impairment. 
Such  evidences  appearing  later  as  imbecility  are  likely  to  be  ascribed  to 
any  accident  or  affection  shown  in  the  child's  postnatal  history.'  It  is  un- 
doubtedly the  case,  however,  and  amply  demonstrated  in  the  later  years 
of  childhood,  that  an  acute  process — as  meningitis  or  intracranial  hemor- 
rhage— may  leave  its  impress  upon  the  brain,  as  seen  in  paresis  and  im- 
paired mentality.  The  division  of  responsibility  for  mental  impairment 
as  between  heredity  and  accident  from  antenatal,  natal,  and  postnatal 
occurrences  is  obviously  impossible.  In  many  instances  both  causes — one 
as  predisposing,  the  other  as  exciting — operate  in  the  same  individual. 


IDIOCY  457 

It  is  a  mistake  to  assume  that  the  brain  in  idiocy  always  presents 
unmistakable  gross  lesions.  Occasionally  the  idiot's  brain  furnishes  no 
macroscopic  indication  of  functional  impairment  in  contour  or  propor- 
tion. The  cellular  elements,  however,  may  show  wide-spread  abnormal- 
ity, with  malarrangement  or  disintegration  of  the  cell  constituents  indi- 
cating degenerative  changes  as  a  result  of  agenesis.  Abiotrophy  (a  term 
applied  to  inherent  weakness)  of  the  nerve  tissues  is  probably  an  inheri- 
tance from  enfeebled  ancestry,  which  yields  to  trifling  intercurrent 
causes,  especially  during  the  periods  of  stress. 

The  question  of  the  normality  of  the  brain  which  yields  so  readily  to 
the  accidental  disturbances  of  childhood  has  been  much  discussed  and 
will  probably  never  be  satisfactorily  settled.  The  same  degree  of  gross 
disturbance  is  frequently  observed  in  adult  brains  with  but  trifling  or 
transient  impairment  of  function.  It  is  noticeable  that  the  most  disas- 
trous results  to  mentality  from  such  causes  occur  during  infancy  and 
earlier  childhood,  the  period  of  rapid  brain  growth,  and  that  after  the 
eighth  year  (completion  of  brain  growth)  a  certain  degree  of  immunity 
from  such  extreme  effects  exists.  How  much  these  facts  are  due  to  the 
survival  of  the  fittest  is  still  a  question. 

Idiocy,  imbecility,  feeble-mindedness,  and  backwardness  are  terms 
used  to  express  the  extent  of  mental  deficiency,  the  indications  of  which 
are  varying  degrees  of  departure  from  the  average  at  a  given  age.  The 
early  symptoms  are  obscure,  and  frequently  no  hint  of  the  congenital 
defect  may  appear  before  the  completion  of  the  first  year.  One  test  of 
mentality  from  the  earliest  to  the  latest  development  of  that  function 
probably  best  determines  the  degree  of  deficiency, — the  test  of  attention. 
Its  absence  or  impairment  is  held  to  correspond  to  the  degree  of  mental 
defect.  Usually  physical  signs  and  motor  defects  in  infancy  accompany 
imbecility,  such  as  inability  to  support  the  head,  sit  alone,  support  the 
body,  or  walk  at  periods  when  these  functions  are  ordinarily  established. 
Mere  muscular  weakness,  however,  may  be  misleading,  since  malnutrition 
and  rhachitis  (both  in  infants  and  older  children)  are  frequently  re- 
sponsible for  these  conditions.  Marked  abnormalities  of  the  head,  in 
size  and  contour,  with  other  stigmata  of  degeneration,  such  as  premature 
closure  of  fontanelles,  persistence  of  lanugo,  misshapen  ears,  high-arched 
or  cleft  palate,  harelip,  frontal  or  basilar  encephalocele,  spina  bifida, 
genital  abnormalities,  and  accessory  fingers  and  toes,  are  occasionally 
corroborative  signs  of  imbecility.  Spastic  plegic  conditions  are  always 
suggestive  of  prenatal  accident.  The  history  of  heredity,  gestation,  and 
parturition,  as  well  as  that  of  accidents  and  ailments  since  birth,  may 
furnish  a  clue  to  the  diagnosis.  But  the  degree  of  attention  and  purpose- 
ful movements  will  always  furnish  the  most  important  information  con- 
cerning the  mental  development  of  the  child.  In  this  connection  a 
fourth  class  of  defectives  must  be  remembered, — viz.,  children  of  tardy 
development,  the  so-called  backward  children,  whose  only  fault  is  ex- 
pressed in  the  term. 

Four  well-defined  types  of  congenital  idiocy  among  the  many  varieties 


458  DISEASES    OF    THE    NERVOUS    SYSTEM 

may  be  mentioned,  on  account  of  their  uniformity  in  history  and  symp- 
toms.— viz.,  cretinism,  Mongolian  idiocy,  amaurotic  family  idiocy,  and 
epileptic  idiocy.  vFor  description  of  the  first,  see  Disorders  of  Thyroid 
Glaud.  ) 

The  Mongolian  or  Calmuck  type  (Figs.  164  to  168)  is  named  for  its 
cranial  and  facial  resemblance  to  that  race,  especially  in  the  inclination 
of  the  palpebral  fissures  and  a  peculiar  development  of  the  epicanthic 
fold.  They  are  usually  good-natured,  round-headed,  undersized,  but 
not  disproportionate  nor  repulsive  children.  The  prominent  papillse  in 
infancy  and  the  deeply  fissured  tongue  in  childhood  are  said  to  be  found 
in  no  other  class  of  imbeciles  (Fig.  166). 

Mongolism  is  much  more  frequently  met  with  in  Great  Britain,  espe- 
cially in  England,  than  on  the  Continent  or  in  the  United  States.  Ex- 
haustion and  age,  especially  of  the  mother,  is  claimed  as  an  etiologic 
factor  in  the  production  of  this  type,  the  greater  number  being  found 
among  the  youngest  children  of  large  families.  Consanguinity,  syphilis, 
and  alcoholism  occur  in  the  ancestry  of  these  children  with  sufficient 
frequency  to  attract  attention.  Antisyphilitic  treatment  has  thus  far 
produced  no  amelioration  of  the  condition.  To  cretins  they  present  a 
marked  contrast  in  the  clear  complexion  and  smooth,  white  skin.  The 
dark  hair  is  fine,  soft,  and  straight.  There  is  no  puffiness  of  the  eyes  nor 
puckering  of  brows.  The  forehead  may  be  wrinkled  transversely  from 
action  of  the  occipitofrontalis  in  elevating  the  eyelids,  but  not  from 
myxoedematous  redundancy  of  skin.  The  head  is  brachycephalic,  with 
flattened  instead  of  overhanging  occiput  (Fig.  165).  The  premature 
ossification  of  the  base  of  the  skull,  with  the  high  arching  of  the  palate, 
may  be  responsible  for  the  backward  encroachment  of  the  vomer  in  the 
pharyngeal  vault  and  the  common  tendency  to  adenoid  growths  in  these 
eases.  The  features  and  extremities  are  cleaner  cut  and  better  formed. 
A  peculiar  incurvation  of  the  little  fingers  has  been  observed,  but  this 
peculiarity  is  not  constant  nor  is  it  confined  to  this  class  of  children.  The 
voice  is  coarse  and  guttural,  in  which  respect  it  resembles  that  of  cretin- 
ism. They  are  not  so  dull,  apathetic,  nor  slow  and  clumsy  in  move- 
ments as  the  cretin.  They  are  prone  to  congenital  heart  defects,  and 
show  feeble  resistance  to  the  diseases  of  childhood,  and  especially  to 
pneumonia.  The  fact  that  they  early  succumb  to  disease  may  explain, 
in  part,  the  infrequency  of  the  recognition  of  this  class  of  defectives. 
The  term  imbecility  is  not  applicable  to  all  cases  of  Mongolism,  as  the 
degree  of  mental  impairment  shows  a  wide  range  of  gradation,  extend- 
ing from  mere  backwardness  to  hopeless  idiocy.  The  former  condition 
is  illustrated  by  Fig.  168  and  the  latter  by  Fig.  167. 

Many  older  infants  and  children  present  evidences  of  the  cause  of 
their  mental  deficiency  in  physical  defects,  such  as  hydrocephaly  or  mi- 
crocephaly, spastic  plegias,  contractures,  and  deformities.  They  are  usu- 
ally short-lived,  though  unfortunately  many,  even  congenital  idiots,  con- 
tinue a  vegetative  existence  into  adult  life.  The  greatest  interest  attaches 
to  the  degree  of  mental  defect  and  the  possibility  of  improvement. 


Fig.  164. — Mongolian  imbecility.    Aged  9  years.    (Dr.  J.  D.  Merrill.) 


Fig.  165.— Mongolian,  showing  flat  occiput.  Fig.  lfifi.— Mongolian  imbecility,  showing  large 

Assured  tongue.     (Dr.  J.  D.  Merrill.) 


Fig.    167. — Mongolian    imbecility. 
Age,  1  year.     (Dr.  G.  H.  Vaughan.) 


Fig.  16S.— Slight  degree  of  Mongolism. 
Age,  15  months. 


AMAUROTIC    FAMILY    IDIOCY  459 

Sensorial  or  idiots,  by  deprivation  due  to  congenital  deaf-mutism, 
with  blindness,  are  susceptible  of  a  high  degree  of  mental  development 
by  proper  methods  of  edueation.  So,  too,  much  may  be  done  for  children 
of  the  imbecile  class  in  institutions  especially  adapted  for  this  work. 

The  merely  backward  child,  outclassed  at  school,  should  also  receive 
the  benefit  of  specialized  educational  training.  This  cannot  be  accom- 
plished in  the  environments  of  the  ordinary  home,  nor  in  schools  whose 
curricula  are  graded  to  meet  the  requirements  of  the  average  intellect. 
It  should  be  remembered  that  backwardness  in  school  is  frequently  due 
to  physical  rather  than  mental  defect — eye,  ear,  adenoids,  etc. — in  which 
correction  removes  the  handicap  in  the  ordinary  educational  methods. 

Early  diagnosis  of  mental  impairment  is  important,  as  special 
methods  of  training  are  successful  in  a  direct  ratio  to  its  early  adoption. 
The  possibilities  of  prophylaxis  is  a  question  of  paramount  importance. 
"With  heredity,  and  with  legislation  restricting  reproduction  by  neurotics 
and  defectives,  the  physician  has  little  to  do.  The  march  of  civiliza- 
tion carries  with  it  the  steadily  increasing  discrepancy  between  the  in- 
fant head  and  the  maternal  pelvis.  The  accoucheur  may  do  much 
to  shorten  the  duration  of  labor.  The  supervision  of  the  pregnant 
woman  may  forestall  or  avert  many  of  the  accidents  in  utero.  Super- 
vision of  the  family  may  anticipate  or  mitigate  many  of  the  cerebral 
disorders  of  infancy. 

AMAUROTIC    FAMILY   IDIOCY. 

Amaurotic  family  idiocy  is  a  name  given  to  a  disease  the  symptoms 
of  which  appear  in  children  who  are  apparently  normal  during  the  first 
few  months  of  life   (Fig.  169).     It  is  a  distinctly  familial  rather  than 


Fig.  169.— R.  F.,  nged  11  months.    Before  development  of  symptoms  of  amaurotic  family  idiocy. 

hereditary  affection.    Frequently  two  in  one  family,  and  in  one  instance 
three  children  in  a  family  of  five,  have  been  reported. 

Etiology. — The  parents   are,   with  rare   exceptions,   Jews   and   fre- 


460 


DISEASES    OF    THE    NERVOUS    SYSTEM 


quently  of  neurotic  type.  Amaurotic  family  idiocy,  as  at  present  under- 
stood, is  probably  due  to  defective  vitality  or  to  a  degenerative  tendency 
in  the  gray  matter  of  the  central  nervous  system.  The  cause  is  unknown. 
Of  the  various  theories  advanced — as  toxins  in  the  mother's  milk 
(Hirsch)  ;  abiotrophy  (Gowers)  ;  deficiency  of  lecithin  in  the  infant's 
food  (author) — all  lack  confirmation  from  the  limited  number  of  obser- 
vations. 

Symptoms. — The  symptoms,  taken  as  a  whole,  form  a  unique  picture. 
The  onset  is  insidious,  and  the  recognition  of  the  disease  in  its  early 
stages  may  be  impossible.  The  first  intimation  of  abnormality  may  be 
some  backwardness  in  muscular  development, — as  inability  to  support  the 
head,  stand,  or  walk  at  the  usual  time.  In  older  infants  these  functions, 
having  been  previously  acquired,  are  lost.  In  explanation  of  this,  some 
trifling  indisposition  is  cited.     The  muscular  atony,  particularly  if  the 


Fig.  170.— Amaurotic  family  idiocy.     Same  patient  as  Fig.  169,  at  22  months. 

child  be  bottle-fed,  is  frequently  attributed  to  rhachitis,  and  the  con- 
vulsive seizures  may  be  erroneously  diagnosed  as  tetany.  Occasionally 
the  physician  may  be  the  first  to  discover  defective  vision.  Unless  famil- 
iar with  the  disease,  or  particularly  on  his  guard,  he  will  fail  in  his  diag- 
nosis until  unmistakable  evidences  of  blindness  lead  to  an  ophthalmo- 
scopic examination.  The  pathognomonic  sign  in  found  in  the  eye- 
ground,  which  shows  a  dark  reddish-brown  or  terra-cotta  colored  circular 
patch  occupying  the  site  of  the  macula  lutea.  This  is  surrounded  by  a 
.larger  whitish  zone,  about  two  or  two  and  one-half  times  the  diameter 
of  the  optic  disk,  through  which  the  retinal  vessels  of  this  area  may 
usually  be  seen  (Pig.  171).    Later,  complete  optic  atrophy  develops. 

The  picture  of  an  advanced  case  is  that  of  a  well-nourished  child, 
from  one  to  two  years  of  age,  unable  to  walk,  stand,  sit,  or  even  to  sup- 
port his  head  (Figs.  170  to  174) .  There  may  be  a  history  of  oft-recurring 
clonic  spasms.  The  reflexes,  both  superficial  and  deep,  are  exaggerated, 
with  spasticity  and  paralysis  of  the  extremities.     Hyperesthesia  and 


AMArKOTIC    FAMILY    IDIOCY 


4G1 


hyperacusis  (Sachs),  increased  acoustic  motor  reaction  (Oppenheim), 
may  be  so  marked  that  slight  disturbance  by  touch  or  sound  will  precipi- 
tate a  general  convulsion  (Fig.  174).  A  symptom  sometimes  noted  is  an 
occasional  outburst  of  laughter  which,  with  the  sightless,  staring  eyes  and 
expressionless  face,  produces  an  uncanny  effect.  There  may  be  constant 
nystagmus,  conjugate  deviation,  or  strabismus.  Deglutition  may  be  im- 
paired or  difficult,  although  the  appetite  and  digestion  remain  remarkably 

good.    In  the  later  stages  loss  of 

Wp  adipose  and  general  innutrition 

^Tj^d^k.  make    their    appearance.      Tem- 

y-apT  perature   changes   are  not   con- 

r  j£jS|         r  '£%  stant  or  significant.     With  the 


Fig.  172.— Ethel  N.,  aged  1  year.    Amaurotic  family 
idiocy.    (Dr.  A.  R.  Martin.) 


Fig.  173. 


-Amaurotic   family  idiocy.    Girl  16 
months  old. 


developing  blindness  there  is  mental  retrogression  until  complete  idiocy 
obtains.  In  some  cases  there  is  almost  continuous  moaning  and  drooling 
of  saliva  (Fig.  170). 

Prognosis. — The  child  rarely  lives  longer  than  two  years  after  the 
development  of  symptoms.  Death  usually  occurs  from  asthenia  or  some 
intercurrent  disorder  during  convulsions. 

Lesions. — Post-mortem  records  show  wide-spread  degeneration  of  the 
gray  matter  of  the  entire  central  nervous  system,  from  which  the  gang- 
lion cells  have  almost  entirely  disappeared  by  disintegration.  There 
is  also  seen  some  deficiency  in  the  development  of  the  cerebral  white 
fibres  and  a  degeneration  of  the  pyramidal  tracts  in  the  lateral  as 
well  as  in  the  anterior  columns  of  the  cord  (Sachs).  The  character- 
istic cloudy  area  of  the  eye  fundus  is  due  to  opacity  from  the  degen- 
erated ganglionic  layer  of  the  retina.      The  liver-colored  spot  is  that 


462 


DISEASES    OF    THE    NERVOUS    SYSTEM 


portion  of  the  macula  lutea  in  which  there  are  no  ganglion  cells,  the 
pigment  of  the  chorioid  and  blood-vessels  showing  through. 

Treatment. — No  treatment  is  known  to  arrest  the  disease.  As  a 
prophylactic  measure  increase  of  lecithin  in  the  infant's  food  is  worthy 
of  trial;  hence,  efforts  to  improve  the  mother's  milk  or  a  change  to  the 

wet-nurse  is  advisable  in  cases  where 
the  disease  is  suspected.  Pats,  rich 
in  lecithin,  may  be  obtained  from  egg 
yolk,  which  should  enter  into  the  food 
of  the  bottle-fed.  Daily  massage  with 
fat  inunctions  should  not  be  neg- 
lected. 

PARETIC   DEMENTIA. 

Paretic  dementia  is  rarely  seen  in 
children.  When  it  does  occur  in  early 
infancy  it  is  usually  mistaken  for 
imbecility,  which,  symptomatically, 
it  closely  resembles.  It  is  usually 
due  to  hereditary  syphilis  causing  a 
diffuse  meningoencephalitis  with  re- 
sultant lesions  similar  to  those  found 
in  adult  cases. 

Occurring  in  an  apparently  nor- 
mal child,  after  the  age  of  five  years, 
the  precursory  symptoms  may  begin 
with  convulsions  and  elevation  of  tem- 
perature suggestive  of  meningitis. 
The  attacks  may  be  repeated  at  inter- 
vals of  several  weeks,  after  which  the 
child 's  mind  begins  to  show  deteriora- 
tion. Vertigo  and  epileptiform  at- 
tacks are  common,  followed  by  para- 
lytic disorders  in  the  lower  extremities 
which  interfere  with  walking.  Mem- 
ory fails ;  the  character  changes ;  the 
child  becomes  apathetic  and  develops 
'scanning,"  and  control  of  the  limbs 


Fig.  174.— B.  F.,  aged  22  months,  one  week 
before  death.  (Sister  of  R.  F.,  Fig.  169).  Con- 
vulsion of  amaurotic  family  idiocy. 


general  tremors ;    the  speech  is 
and  sphincters  is  lost. 

The  grandiose  delusions  of  the  adult  type  are  not  seen  in  the  infantile 
form. 

Prom  two  to  four  years  may  elapse  between  the  initial  symptoms 
and  death.  The  child  is  meanwhile  reduced  to  a  state  of  mental  and 
physical  helplessness. 

In  view  of  its  syphilitic  etiology,  mercurials  and  iodides  are  indi- 
cated, with  some  hope  of  benefit  if  taken  in  the  early  stage.  Unfortu- 
nately, the   diagnosis  is  rarely  established  until  structural  alterations 


INSANITY  463 

have  occurred  in  the  brain  cells.     The  average  course  in  childhood  is 
very  rapid. 

INSANITY. 

Distinguished  alienists  claim  that  insanity  is  rare  in  infancy  and 
childhood,  but  that  all  the  known  varieties  have  been  observed  at  this 
period.  Statistics  of  a  large  number  of  cases  of  insanity  show  that 
about  one  and  one-half  per  cent,  are  recorded  as  congenitally  insane, 
and  that  two  and  one-half  per  cent,  acquired  the  disease  during  child- 
hood. Such  statistics,  made  up  from  institutional  records,  are  obviously 
misleading  since,  from  the  character  of  the  patients  in  public  and  chari- 
table institutions,  veritable  and  complete  histories  in  a  large  number  of 
cases  are  impossible.  Such  reports,  moreover,  do  not  include  a  large 
number  of  insane  children  outside  of  institutions  and  who  rarely  come 
under  the  eye  of  the  alienist.  It  is  highly  probable  that  statistics  of 
mental  aberration  gathered  from  the  view-point  of  the  family  physician 
would  show  a  large  increase  over  this  percentage  of  psychic  disturbances 
in  children. 

In  a  work  of  this  kind  any  effort  at  extensive  classification  of  in- 
sanity is  clearly  out  of  place.  For  a  study  of  this  disease  the  reader  is 
referred  to  the  standard  treatises  on  that  subject.  There  is  a  growing 
belief  that  many  psychopathic  states  of  early  childhood  may  be  fore- 
runners of  the  increasing  insanity  common  to  middle  life.  The  strong 
hereditary  tendency  of  insanity  is  accepted  beyond  question.  Many  of 
the  exciting  causes, — as  traumatisms,  extremes  of  heat  and  cold ;  cerebral 
diseases, — as  epilepsy,  acute  infections,  reflex  irritations,  fright,  exhaus- 
tion from  school  work,  environmental  conditions,  and  habit, — are  daily 
gaining  recognition. 

Such  mental  defects,  both  developmental  and  acquired,  as  idiocy 
and  feeble-mindedness,  although  insane  delusions  may  accompany  the 
latter,  are  not  included  in  the  following,  as  they  are  discussed  else- 
where. 

The  forms  of  recognized  insanity  most  frequently  seen  in  children 
are  acute  mania,  melancholia,  epilepsy,  and  insane  hallucinations.  These, 
with  the  exception  of  the  last-named,  occur  in  connection  with  the  acute 
infectious  diseases, — as  scarlet  fever,  measles,  acute  rheumatism,  pneu- 
monia, and  typhoid,  especially  typhoid.  The  delirium,  not  infrequent 
in  hyperpyrexia,  is  usually  transitory  and  subsides  with  the  decline  of 
temperature ;  but  occasionally  mania  with  delusions  may  continue  for 
months  after  the  termination  of  the  disease. 

A  state  of  melancholia  of  more  persistent  duration  is  not  rare,  both 
in  the  terminal  stage  of  fever  and  as  an  outgrowth  of  the  convalescent 
stape,  and  has  been  considered  as  due  to  the  exhaustive  effect  of  the 
prolonged  disease.  There  is  reason  to  believe  that  many  psychopathies 
are  expressions  of  cerebral  intoxication  from  pathogenic  organisms  pecu- 
liar to  the  parent  disease.  Psychopathies  of  this  seemingly  acute  infec- 
tious variety,  as  a  class,  furnish  the  most  favorable  prognosis,  as  recovery 
is  the  rule  under  «'ood  hygienic  conditions.    A  radical  change  of  environ- 


464  DISEASES    OF    THE    NERVOUS    SYSTEM 

ment  may  be  necessary,  with,  removal  of  objects  or  persons  in  any  way 
associated  with  the  febrile  or  convalescent  period,  during  which  the 
mania,  melancholia,  or  hallucinations  developed.  A  supporting  dietary, 
with  judicious  employment  of  hydrotherapy  and  purposeful  open-air 
occupation,  may  well  exclude  the  routine  use  of  sedatives  or  drugs. 
Unfortunately,  in  rare  instances  a  marked  hereditary  tendency  asserts 
itself  in  these  cases  with  deplorable  results. 

The  effects  upon  mentality  from  traumatism  (particularly  from 
blows  on  the  head),  intracranial  disease,  especially  meningitis,  meningo- 
encephalitis, and  hemorrhage,  as  productive  of  idiotic  and  imbecile 
states,  have  been  presented  in  another  chapter.  The  border  line  between 
imbecility  and  insanity  is  at  times  extremely  vague,  as  is  also  the  differ- 
entiation of  the  phobias  of  the  insane  and  feeble-minded.  Trauma  as 
an  exciting  cause  is  not  infrequently  common  to  both  of  these  mental 
conditions. 

The  hopelessness  of  cure  in  this  class  of  unfortunates  is  as  apparent 
as  the  gross  pathological  lesions  induced  by  the  disease.  Kind  but  firm 
supervision,  with  moral  education,  occasionally  may  direct  the  eccen- 
tricities into  harmless  channels,  as  from  destructive  to  philanthropic 
manias. 

Mania  resultant  from  exposure  to  extremes  of  temperature,  as  from 
insolation,  or  heat  after  prolonged  refrigeration,  though  most  violent  in 
its  manifestations,  subsides,  as  a  rule,  under  appropriate  treatment 
after  a  few  days  or  months  of  alternating  outbreaks  and  remissions. 
The  disease,  however,  may  become  periodic,  especially  if  the  vascular 
changes  in  the  brain  are  permanent.  A  sequel  to  this  form  is  sometimes 
seen  in  violent  outbursts  of  temper,  approaching  maniacal  excitement, 
from  trivial  causes. 

The  removal  of  a  cause  of  reflex  irritation — such  as  intestinal  para- 
sites, ingrowing  toe-nail,  or  preputial  constriction — is  followed  by  the 
subsidence  of  maniacal  symptoms  with  sufficient  frequency  to  demon- 
strate the  etiological  relationship. 

The  most  interesting  phases  of  insanity,  from  the  pediatric  stand- 
point, are  those  forms  due  to  emotional  causes.  These  represent  a  great 
variety  of  psychopathic  conditions,  from  the  extreme  homicidal  or  sui- 
cidal impulses  to  conditions  recognized  only  as  unimportant  psychoses  or 
emotional  eccentricities.  In  most  of  these  forms  of  mental  unbalance, 
the  predominating  element  is  the  inordinate  egotism.  This  egotism,  as 
an  hereditary  defect,  plus  the  environment,  as  an  exciting  cause,  act  and 
react  in  a  vicious  circle  to  the  establishment  of  many  psychopathic  con- 
ditions which  continue  throughout  life.  In  this  class  are  found  the 
paranoias  with  their  endless  variety  of  insane  delusions. 

It  is  not  difficult  to  see  how  the  precordial  apprehensian  of  a  physi- 
cally defective  child  may  develop  into  a  hypochondriasis  or  a  pathopho- 
bia. Again,  in  the  child  without  physical  defect  an  abnormal  self-con- 
sciousness may  be  the  foundation  upon  which  a  foolish  mother  may  help 
to  erect  a  permanent  mysophobia.    In  a  similar  manner  may  the  recita- 


INSANITY  465 

tion  of  stories  of  ghosts  and  hobgoblins,  of  fairy-tales  and  bizarre  occur- 
rences and  crimes  in  real  life,  by  overstimulation  of  the  imagination, 
lead  up  to  monophobia  or  even  to  panphobia.  There  is  always  a  begin- 
ning of  the  unbalancing  of  the  developing  mind  which  may  be  largely 
due  to  environment.  The  early  concept  may,  through  mere  circum- 
stance, most  trivial  in  character,  become  an  insistent  idea.  Impera- 
tive acts,  too  frequently  regarded  as  amusing  or  innocent  peculiarities, 
may,  by  repetition,  gain  firm  control, — each  repetition  weakening  the 
will  until  the  individual  becomes  the  victim  of  morbid  impulses  or  pro- 
pensities. Undoubtedly  many  cases  of  pyromania,  kleptomania,  eroto- 
mania, dipsomania,  morbid  propensities  to  destroy  property,  kill  or  per- 
secute animals,  as  well  as  suicidal  and  homicidal  manias,  owe  their  origin 
to  lack  of  correction  of  the  earliest  manifestations  of  imperative  con- 
ceptions. "  Cranks"  may  owe  to  heredity  their  exaggerated  egotism, 
and  their  special  development  to  their  environments. 

The  hopelessness  of  established  paranoia  lends  additional  emphasis 
to  the  importance  of  the  recognition  of  its  beginning  in  some  of  the 
trifling  eccentricities  of  the  developing  period,  at  a  time  when  judicious 
management  might  arrest  the  morbid  tendency.  Mental  hygiene  requires 
for  the  symmetrical  development  of  mind,  as  does  physical  hygiene  for 
that  of  body,  a  systematic  regimen  of  purposeful  function.  Psychic 
toughening,  like  physical  toughening,  is  accomplished  only  by  the  over- 
coming of  obstacles, — by '  systematic  training  in  the  exercise  of  the  will, 
judicious  and  unobtrusive  direction  of  the  mental  activities  into  whole- 
some channels  with  simple,  practical  daily  problems  of  whose  solution 
the  responsibility  must  clearly  rest  with  the  child.  This  should  replace 
the  modern  tendency  to  pamper  the  child 's  unreasoning  whims  and,  as  it 
were,  to  masticate  and  predigest  his  mental  pabulum.  Disillusioning  of 
the  infant  mind  may  avert  the  phobias  of  later  years. 

Whether  the  underlying  pathology  of  katatonia  be  due  to  vascular 
hypoplasia  or  to  stasis  from  vasomotor  disturbances,  it  is  quite  generally 
conceded  that  dementia  praecox,  in  which  this  symptom  is  most  marked, 
is  frequently  the  result  of  exhaustion.  The  development  of  symptoms 
of  hebephrenia  after  a  long  sickness — as  typhoid  fever,  exhaustive  physi- 
cal exertion,  intense  application  to  study  accompanied  by  insufficient 
food,  rapid  physical  growth,  or  masturbation — is  of  common  clinical 
recognition. 

The  varied  symptoms  may  include  mania,  melancholia,  confusion  of 

ideas  and  varied  delusions  with  the  characteristic  stupor  and  persistent 

obstinacy.    During  the  attacks  the  patients  may  refuse  to  eat  or  attend 

to  any  of  the  bodily  functions,  rendering  catheterization,  enemata,  and 

gavage  necessary.    All  of  these  the  patient  most  stubbornly  resists.     Of 

the  motor  symptoms,  katatonia  is  the  most  marked  and  peculiar.     This 

hypertonic  spasm  of  limbs  and  trunk  may  be  so  extreme  as  to  baffle  all 

efforts  at  passive  flexion.     The  bizarre  attitudes  of  persistent  rigidity, 

seen  in  some  of  these  patients,  are  among  the  curiosities  of  clinical 

medicine. 

30 


466  DISEASES    OF    THE    NERVOUS    SYSTEM 

The  gravity  of  dementia  praacox  with  its  low  percentage  of  recoveries 
renders  important  the  early  recognition  of  its  prodromata,  the  chief 
among  which  is  apathy,  despondency,  and  the  easily  induced  fatigue  in 
a  mind  previously  ambitious  and  alert. 

The  stress  of  pubescence  is  too  frequently  forgotten  in  the  parental 
pride  at  their  rapidly  developing  progeny.  Careful  supervision  of 
pubescent  youth  on  the  part  of  the  family  physician,  with  wise  advice 
as  to  personal  habits  and  the  character  and  amount  of  work  to  be  under- 
taken, may  save  the  child  from  threatened,  hopeless  dementia. 

The  food  should  be  nutritious  but  non-stimulating.  Excess  of  pro- 
teids  should  be  expressly  avoided  in  the  neurotic.  Daily  vigorous  exer- 
cise in  the  open  air,  with  positive  exclusion  of  tobacco,  alcohol,  tea,  and 
coffee,  should  be  insisted  upon.  Studies  and  recitations — reading,  music, 
and  theatre-going — which  strongly  appeal  to  the  aesthetic  or  emotional 
side  of  the  nature  should  be  interdicted. 

TRANSVERSE    MYELITIS. 

Transverse  myelitis  is  an  inflammation  of  the  spinal  cord  with  re- 
sultant motor,  sensory,  and  trophic  disturbances  in  parts  below  the  seat 
of  the  lesion.  In  form  it  may  be  acute,  subacute,  or  chronic.  In  location 
it  may  be  seen  in  the  cervical,  dorsal,  or  lumbar  regions,  but  most  fre- 
quently in  the  dorsal.  Common  causes  in  children  are  traumatisms, 
cold,  acute  infections,  syphilis,  or  tuberculosis  of  the  spine,  hemorrhages, 
or  any  condition  causing  pressure  upon  the  cord  in  any  part  of  its 
extent.  It  has  been  found  that  infants  and  young  children  are  pecu- 
liarly susceptible  to  hemorrage  into  the  cord,  especially  into  the  gray 
matter  of  the  anterior  columns.  This  is  explained  by  its  vascularity, 
softer  consistency,  and  the  inferior  support  afforded  to  its  vessels.  Since 
the  completeness  of  the  motor-sensory  trophic  disturbance  is  dependent 
upon  the  amount  of  pressure  and  the  extent  of  cord  tissue  involved,  it 
follows  that  a  limited  hemorrhage  into  the  anterior  columns  might  pro- 
duce only  partial  paraplegia,  with  unimpaired  sensation  and  very  little 
atrophy,  the  posterior  horns  being  uninvolved. 

From  many  observations  upon  still-born  infants  with  hamiatomyelia, 
also  from  post-mortems  upon  very  young  infants,  it  is  found  that  cord 
hemorrhages  are  not  so  rare  as  was  formerly  supposed.  It  is  probable 
that  transverse  myelitis  may  have  been  frequently  overlooked  in  young 
infants,  the  paralysis  being  attributed  to  other  causes,  or  if  incomplete, 
coming  under  observation  subsequently,  is  supposed  to  be  a  complication 
of  some  later  malady. 

It  is  well  known  that  the  cord  is  remarkably  tolerant  of  a  compres- 
sion which  develops  slowly,  so  that  paraplegic  symptoms  are  late  and  in- 
complete, with  a  tendency  to  recovery.  This  is  well  illustrated  in  Pott's 
disease.  The  myelitis  following  infectious  diseases  may  show  this  char- 
acter of  partial  paraplegia,  with  tendency  to  restoration  of  motility, 
from  a  limited  area  of  spinal  involvement.  This  is  of  interest,  as  the 
acute  infections  appear  to  be  the  commonest  cause  of  myelitis  in  child- 


TRANSVERSE    MYELITIS  467 

hood.  This  disease  has  been  considered  extremely  rare  before  the  age 
of  outdoor  traumatisms  and  exposures,  but  recent  reports  of  myelitis  in 
the  newly  born  presage  a  change  of  opinion. 

The  symptoms  and  course  of  transverse  myelitis  in  childhood  do  not 
differ  essentially  from  those  of  adult  life,  with  the  exception  of  the 
cases  following  the  acute  infectious  diseases  showing  a  less  pronounced 
type. 

The  diagnosis  is  made  from  the  rapid  onset  of  the  paraplegia,  accom- 
panied by  anaesthesia  and  atrophy  of  all  muscles  supplied  by  segments 
below  the  spinal  lesion,  the  involvement  of  bladder  and  rectum,  and 
early  tendency  to  the  formation  of  bedsores.  When  diplegia  results  from 
cervical  lesion,  the  naccidity  and  atrophy  of  the  upper  extremities  is  in 
marked  contrast  with  the  spasticity  of  the  lower. 

Prognosis. — Complete  recovery  is  rare.  In  diplegic  cases  there  is 
danger  of  early  involvement  of  the  cardiac  and  respiratory  functions. 
Lumbar  lesions,  always  attended  by  paresis  of  the  bladder  and  bowel 
and  necrotic  bed-sores,  are  of  grave  import  to  the  extent  of  these  lesions. 
Those  cases  of  myelitis  in  the  dorsal  segment  of  the  cord  due  to  syphilis, 
as  well  as  those  following  acute  infectious  fevers,  offer  the  most  favor- 
able prognosis  as  to  their  ultimate  recovery,  with  the  minimum  impair- 
ment of  the  affected  muscles. 

The  treatment  is  essentially  rest  in  the  strictest  sense  of  the  word.  In 
the  earliest  stage  a  spinal  ice-bag  should  be  applied  over  the  affected 
portion  of  the  cord  for  a  week  or  ten  days,  after  which  a  rubefacient,  as 
an  attenuated  mustard-plaster,  may  be  substituted  over  the  upper  two- 
thirds  of  the  spinal  column.  The  dorsal  decubitus  should  not  be  per- 
sistently maintained,  as  extreme  vigilance  is  necessary  to  prevent  the 
formation  of  bed-sores.  This  will  be  rendered  all  the  more  difficult  by 
the  involuntary  evacuation  of  the  bowels  and  the  dribbling  of  urine. 
A  water-bed  should  be  provided  if  possible.  Too  much  care  cannot  be 
given  to  the  skin,  especially  over  the  buttocks.  All  parts  exposed  to 
pressure  should  be  rubbed  with  diluted  alcohol  or  solutions  of  tannic 
acid  and  dusted  with  powders.  To  the  beginning  sore,  collodion  dress- 
ings may  be  carefully  applied  and  later  there  should  be  thorough  clean- 
ing with  bichloride  of  mercury  (1:  5000)  or  peroxide  of  hydrogen. 

The  condition  of  the  bladder  requires  careful  watching,  with  aseptic 
catheterization.  Cystitis  may  call  for  vesical  irrigation  with  a  two  per 
cent,  solution  of  boric  acid,  and  the  use  of  potassium  acetate  or  urotropin. 
Pads  of  borated  absorbent  cotton  may  be  used  for  bowel  dejections  or 
dribbling  urine. 

The  bowels  should  be  flushed  with  normal  salt  solution.  Calomel 
may  be  given  in  suitable  dosage  to  secure  free  purgation,  whether  there 
be  diarrhoea  or  constipation.    The  diet  must  be  bland  and  nutritious. 

In  syphilitic  cases  potassium  iodide  should  be  administered,  if  the 
stomach  be  tolerant,  or  mercury  by  inunction  may  be  used.  To  over- 
come the  contractures,  extension  is  indicated.  This  may  be  secured  by 
lowering  the  foot  of  the  mattress,  the  patient  being  retained  by  a  strap 


4:68  DISEASES    OF    THE    NERVOUS    SYSTEM 

attached  to  the  head  of  the  bed  and  fastened  to  a  harness  similar  to  that 
used  in  suspension  for  spinal  deformities. 

Oil  inunction  with  gentle  massage,  after  the  subsidence  of  the  acute 
symptoms,  with  later  more  vigorous  massage  of  the  affected  muscles,  to 
which  faradism  may  be  applied — although  of  little  use  to  the  spine — 
will  delay  the  general  atony  and  paresis.  Continued  rest,  cool  bathing, 
spinal  douching,  with  sunlight  and  fresh  air,  will  improve  tone  and 
promote  recovery. 

ACUTE   ANTERIOR  POLIOMYELITIS — INFANTILE   SPINAL   PARALYSIS. 

Actue  anterior  poliomyelitis  is  the  commonest  cause  of  palsy  in  in- 
fancy and  early  childhood.  The  disease  is  so  common  to  this  age  that  it 
is  more  frequently  known  by  the  indefinite  term  of  infantile  paralysis, 
and  also  by  the  more  expressive  term  of  infantile  spinal  paralysis.  Polio- 
myelitis anterior  acuta,  in  distinction  from  a  chronic  form  of  rare  occur- 
rence, is,  as  its  name  implies,  an  acute  inflammation  in  the  anterior  horns 
of  the  gray  matter.  Opportunities  for  post-mortem  examination  in  the 
early  stage  of  this  disease  are  so  infrequent  that  doubt  still  exists  as  to 
the  exact  character  of  the  primary  lesion.  An  infection  it  undoubtedly 
must  be  considered,  both  from  its  mode  of  onset  and  from  its  many 
analogies  to  other  infectious  diseases,  although  the  specific  etiologic 
microbe  or  toxin  is  not  known.  If  it  begin  as  an  infective  endarteritis 
of  the  vessels  entering  the  anterior  median  fissure,  it  soon  extends  to  the 
adjacent  gray  structures  with  resultant  parenchymatous  and  interstitial 
degeneration.  Atrophy  and  diminution  of  the  multipolar  ganglionic 
cells  have  been  observed  as  a  constant  change  in  late  post-mortems,  and 
were  formerly  urged  as  the  primary  specific  lesion  of  the  disease. 

The  degenerative  process  may  extend  to  the  white  matter  of  the 
affected  half,  the  nerve-fibres  from  the  atrophied  cells  disappear,  and  the 
entire  segment  show  evidence  of  general  sclerotic  changes.  Macroscopi- 
cally,  the  affected  side  is  seen  to  be  smaller  than  the  opposite  half. 
Occasionally  both  horns  are  involved.  The  richness  in  blood  supply  of 
the  anterior  gray  matter  has  been  assigned  as  a  reason  for  the  frequency 
of  its  selection  for  the  initial  toxic  lesion.  Some  fibres  of  the  ante- 
rior nerve  roots  show  degeneration  which  extends  throughout  their 
course  to  their  distribution  in  the  muscles  which,  ultimately,  share  in 
the  changes. 

The  disease  is  confined  almost  exclusively  to  the  period  between  the 
sixth  month  and  the  fifth  year,  eighty  per  cent,  of  all  cases  occurring 
in  the  first  three  years  of  life.  Rare  cases  are  reported  in  early  infancy 
and  it  is  less  often  seen  after  the  sixth  year,  although  no  doubt  it  occurs 
more  frequently  in  the  adult  than  is  generally  supposed,  being  diagnosed 
as  multiple  neuritis.  No  predisposition  as  to  heredity,  sex,  race,  or 
physical  condition  has  been  observed.  It  occurs  with  the  greatest  fre- 
quency during  the  summer  season,  usually  in  children  in  apparently 
good  health,  yet  it  is  known  to  follow  or  to  complicate  acute  infectious 
diseases,  as  measles,  scarlatina,  and  typhoid  fever.    A  few  limited  epi- 


ACUTE    ANTERIOR    POLIOMYELITIS  469 

demies  have  been  reported  in  communities  where  at  the  time  no  other 
infection  was  prevalent.  Occasionally  a  more  or  less  recent  history  of  a 
fall  or  blow  is  given,  and  quite  as  frequently  exposure  to  wetting  or 
sudden  change  of  temperature  is  reported  as  preceding  the  attack. 

Clinically,  four  periods  in  this  disease  are  usually  recognized:  first, 
stage  of  onset ;  second,  stage  of  paralysis ;  third,  stage  of  improvement ; 
fourth,  stage  of  atrophy  and  deformities.  The  onset  is  always  sudden, 
with  febrile  symptoms  ranging  from  slight  indisposition,  with  but  little 
elevation  of  temperature,  to  symptoms  of  profound  intoxication  with 
high  temperature  (102°-104°  F.,  39°-40°  C),  vomiting,  headache,  occa- 
sionally convulsions,  and  rarely  coma.  There  may  be  pain  and  tender- 
ness over  the  trunk  and  particularly  in  the  extremities,  the  picture 
simulating  that  of  an  acute  exanthem  before  the  appearance  of  a  rash. 
This  stage  may  last  from  three  hours  to  as  many  days,  during  which  the 
diagnosis  is  rarely  made.  A  few  reports  of  tardy  development  of  paraly- 
sis have  appeared,  from  one  to  two  weeks  elapsing  between  the  beginning 
of  the  first  and  second  stages.  Upon  subsidence  of  the  acute  symptoms 
it  is  discovered,  too  frequently  by  accident,  that  the  child  has  lost  the 
use  of  one  or  more  limbs.  Occasionally  all  of  the  extremities  are  in- 
volved, as  well  as  some  of  the  trunk  muscles.  The  sphincters  and  respira- 
tory muscles  escape.  Not  infrequently  the  acute  stage  is  wanting. — a 
healthy  child,  the  night  before,  showing  paralysis  the  following  morning 
without  other  symptoms.  This  form  of  spinal  paralysis  has  been  known 
to  occur  in  a  child  at  play,  his  inability  to  walk  developing  without 
warning.  The  paralysis  may  be  mono-,  hemi-,  para-,  or  diplegic  in  form. 
A  review  of  a  large  number  of  cases  shows  the  following  percentage  of 
primary  involvement  of  different  members: 

Per  cent.  Per  cent 

One   lower   extremity    40       Both  lower  and  one  upper    3 

Both    lowers     31       One  upper    3 

All  extremities    14       Other   forms    2 

One    lower    and    one    upper,    usually 
crossed    7 

Rarely  all  the  muscles  of  an  extremity  are  involved.  In  a  large 
majority  of  the  cases  it  is  the  extensors  that  suffer  and  of  these  occasion- 
ally only  a  single  group.  This  selection  of  groups  is  rather  character- 
istic of  poliomyelitis.  Of  the  lower  extremities  the  groups  of  muscles 
are  most  frequently  affected  in  the  following  order:  the  peronei,  the 
tibialis  anticus,  and  quadriceps  femoris,  and  of  the  upper,  the  deltoid, 
the  supinatores,  and  triceps.  Exceptionally  the  flexors  are  involved,  as 
the  gastrocnemius  and  soleus.  Although  a  number  of  muscles  may  be  in- 
volved in  the  beginning  of  the  second  stage,  movement  is  recovered  in  the 
majority,  as  a  rule,  within  a  few  weeks  or  months — a  peculiarity  of 
this  disease — leaving  one  or  more  groups  only  of  one  or  more  members 
paralyzed,  thus  completing  the  second  stage  of  the  disease,  which  may 
have  begun  as  a  diplegia  or  hemiplegia,  to  terminate  in  a  monoplegia  or 
crossed  variety. 


470  DISEASES    OF    THE    NERVOUS    SYSTEM 

Pain  or  hyperesthesia  over  the  affected  muscles  and  their  nerves  are 
rarely  seen  in  this  stage,  although  sensation  is  not  impaired.  Tendon 
reflexes  of  the  muscles  involved  are  lost.  Faradic  excitability  gradually 
diminishes  and  is  finally  lost,  while  galvanic  response  increases  in  those 
muscles  which  ultimately  show  permanent  impairment,  in  all  of  which 
the  reaction  of  degeneration  is  well  marked. 

The  resultant  deformity  is  often  seen  in  one  lower  extremity  which 
is  atrophied,  shortened,  and  cold,  as  with  relaxed  ligaments  it  hangs  a 
helpless  appendage  to  the  body.  More  frequently,  however,  some  power 
is  left,  the  deformity  taking  the  form  of  talipes  varus,  valgus,  equinus, 
or  equinovarus,  according  to  the  different  degrees  of  paralysis  of  the 
tibial  or  peroneal  groups  of  muscles.  The  quadriceps  rarely  escapes,  so 
that  leg  extension  is  lost,  causing  the  familiar  flail  gait  in  walking.  The 
rarer  deformities  of  the  upper  extremities  usually  appear  in  subluxation 
of  the  shoulder  with  deltoid  atrophy, — the  arm  swinging  helpless  at  the 
side  or  the  scapula  may  stand  out  wing-like  from  involvement  of  the 
serratus  magnus.  The  forearm  only  may  show  atrophy  with  loss  of 
supination  and  relaxed  wrist.  Contractures  occasionally  ensue  from  the 
action  of  opposed  muscles,  so  that  the  hand  is  carried  in  extreme  prona- 
tion with  the  fingers  flexed. 

The  diagnosis  is  never  made  until  the  second  stage,  as  it  depends  en- 
tirely upon  the  form  of  the  paralysis.  The  nature  of  the  spinal  lesion  is 
revealed  by  certain  characteristics  which  can  rarely  be  misinterpreted, — 
such  as  the  sudden  development ;  unimpaired  sensation ;  flaccidity  of 
involved  muscles  with  their  loss  of  tendon  reflex;  atrophic  changes; 
early  spontaneous  improvement  in  certain  groups,  and  the  reaction  of 
degeneration  in  muscles  permanently  paralyzed.  Differentiation  must 
be  made  from  multiple  neuritis,  cerebral  paralysis,  transverse  myelitis, 
Erb's  palsy,  and  the  pseudoparalyses  of  rhachitis,  scorbutus,  and  acute 
rheumatism. 

Prognosis. — Acute  anterior  poliomyelitis  is  rarely  if  ever  fatal  to 
life.  The  extent  and  permanency  of  the  paralysis  is  the  important  ques- 
tion, the  answer  to  which  cannot  be  predicted  from  the  extent  of  primary 
involvement,  as  extensive  diplegia  may  terminate  in  a  limited  mono- 
plegia or  in  complete  recovery,  while  initial  monoplegia  may  persist, 
with  complete  functional  loss  of  the  member.  Early  loss  of  faradic  irri- 
tability and  rapid  wasting  are  of  grave  import  for  the  muscles  involved. 
Partial  response  and  subsequent  improvement  in  susceptibility  to  faradic 
stimulation  are  favorable  prognostics  of  the  ultimate  return  of  function. 
The  hopefulness  of  the  case  depends  upon  the  duration  and  degree  of 
the  atrophy,  and  non-response  to  galvanism.  Clinical  experience  proves 
the  importance  of  reservation  in  prognosis  and  perseverance  in  the  treat- 
ment of  apparently  hopeless  cases.  Complete  recovery  is  rare,  and  in 
long-standing  cases  is  not  to  be  expected. 

Treatment. — The  first  stage  should  be  treated  like  any  other  acute 
febrile  onset, — by  prompt  elimination,  by  induced  catharsis,  and  by  bro- 
mides.    Even  antipyrin  should  be  given  if  the  excitement  warrant.     If 


TUMORS   OF    THE    SPINAL   CORD  471 

acute  spinal  lesions  seem  probable  from  epidemic  prevalence,  on  indica- 
tion of  motor  disturbance,  an  ice-bag  should  be  applied  to  the  spine,  bro- 
mides pushed,  and  ergot  administered  every  two  hours.  In  the  second 
stage  the  affected  muscles  should  be  masseed  twice  daily  and  the  member 
supported  to  prevent  dragging  upon  the  relaxing  ligaments.  After  the 
first  month,  regular  application  of  faradic  electricity  may  aid,  not  in  re- 
storing the  degenerate  nerves,  for  their  ganglion  cells  are  atrophied, 
but  in  maintaining  the  nutrition  of  the  muscular  fibres  and  lessening 
atrophy  from  long  disuse. 

The  effects  of  heat  in  maintaining  the  circulation  and  promoting 
metabolism  should  not  be  forgotten.  Treatment  should  be  persisted  in 
for  months  and  even  years,  as  evidences  of  its  beneficial  effects  are 
abundant. 

The  orthopaedic  surgeon  can  do  much  by  means  of  operation  and 
mechanical  appliances  for  the  resultant  deformities. 

Transplantation  of  tendons  and,  recently,  transplantation  of  nerves, 
have  been  followed  in  some  cases  by  recovered  function. 

TUMORS   OF    THE    SPINAL    CORD. 

Tumors  of  the  spinal  cord  are  occasionally  found  in  young  children. 
They  may  be  syphilitic,  tuberculous,  carcinomatous,  sarcomatous,  glio- 
matous,  hemorrhagic,  or  metastatic.  As  the  etiology  of  many  of  these 
neoplasms  is  obscure,  so  must  be  the  cause  of  their  location  in  the  spinal 
canal. 

Presumably  traumatism  plays  an  important  role  in  their  origin,  espe- 
cially in  systemic  conditions  favorable  to  their  development,  as  tuber- 
culous, syphilitic,  and  other  dyscrasia?. 

The  location  of  the  tumor,  whatever  its  nature,  produces  focal  symp- 
toms usually  unilateral,  at  first  motor,  sensory,  and  trophic,  with  late 
or  early  symptoms  of  compression  myelitis  similar  to  that  in  caries  of 
the  vertebrae. 

The  treatment  depends  upon  the  cause,  which  may  sometimes  be  con- 
jectured by  associated  conditions.  In  some  rare  instances  surgery  may 
hold  out  a  fair  promise  of  relief. 

SYRINGOMYELIA MYELOSYRINGOSIS. 

This  disease,  which  is  characterized  by  cavity  formation  in  the  spinal 
cord,  is  rarely  observed  in  children.  The  cervical  portion  is  the  usual 
seat,  although  the  process  may  extend  to  all  parts  of  the  cord  or  the 
medulla,  producing  symptoms  characteristic  of  the  structure  involved. 
Anterior  horn  lesions  cause  paralysis,  lost  reflexes,  and  atrophy  in  the 
muscles  of  the  affected  segment.  There  is  often  a  unilateral,  or,  at 
least,  an  uneven  distribution  of  two  sides. 

Destruction  of  the  central  gray  matter  gives  rise  to  trophic  changes 
and  vasomotor  disturbances,  such  as  fissures  or  glossiness  of  the  skin 
of  the  fingers,  brittle  nails,  painless  felons  with  phalangeal  necrosis,  boils, 
and  dermal  or  subdermal  atrophies. 


472  '  DISEASES    OF    THE    NEEVOUS    SYSTEM 

Invasion  of  the  posterior  columns  is  followed  by  analgesia  and  sen- 
sory disturbances  which  are  pathognomonic.  There  is  dissociation  of 
thermo-anaesthesia  from  tactile  anaesthesia,  which  is  typical  of  syringo- 
myelia, although  it  is  occasionally  seen  in  hysteria  and  anaesthetic 
leprosy. 

The  symptoms  are  focal  and  mark  the  location  and  progress  of  the 
destructive  process  in  the  cord. 

The  diagnosis  from  hydromyelia  (a  congenital  dilatation  of  the 
central  canal),  from  hemorrhages,  tumors,  syphilitic  and  tubercular 
growths,  must  be  made  from  the  gradual  onset,  the  variety  and  distribu- 
tion of  its  manifestations,  and  absence  of  specific  constitutional  disease; 
from  hysteria,  by  the  development  of  trophic  changes  and  plegias  with 
degenerative  reaction  in  the  muscles. 

The  disease  progresses  by  stages  and  is  incurable. 

HEREDITARY   SPINAL   ATAXIA — FRIEDREICH'S   DISEASE. 

Hereditary  spinal  ataxia  is  a  family  affection  in  which  there  is  at- 
tenuation of  the  spinal  cord,  most  marked  in  the  dorsal  region  and  in 
the  direct  cerebellar  tract.  This  is 
due  either  to  inherited  lack  of  devel- 
opment, to  disappearance  of  nerve- 
fibres,  or  to  sclerotic  shrinking.  Sev- 
eral generations  or  a  number  of 
children  in  the  same  family  may  be 
affected.  Syphilis,  neuroses,  and  al- 
coholism in  parents  are  regarded 
as  predisposing  causes.  The  disease 
develops  usually  between  the  fifth 
and  fifteenth  years,  more  often  in 
males,  and  may  follow  acute  infec- 
tions. 

Symptoms. — Ataxia  and  weakness 
beginning  in  the  legs,  steadily  in- 
creasing, and  spreading  until  in  four 
or  five  years  the  arms  are  involved,  is 
characteristic  of  the  onset.  Loss  of 
patellar  reflex  occurs  early,  with 
atrophy  of  muscles.  Later  disturb- 
ances of  speech  (slow  and  scanning), 
nystagmus,  mental  impairment,  and 
contractures  from  paralysis  of  the 
muscles,  follow.  As  a  rule,  no  vesical 
or  rectal  disturbances  occur.  Charac- 
teristic plantar  flexions  of  the  foot, 

.,,  ,  ,        .      ,       ,         „  „  Fig.  175.— Cupped  foot. 

with  extreme  dorsi-plantar  flexions  of 

the  first  two  toes  (cupped  foot)  (Fig.  175),  and  spinal  scoliosis,  are  seen. 

Oscillation  of  the  head  and  choreiform  movements  of  the  extremities 


LANDRY'S  PARALYSIS  473 

may  appear.  Bulbar  symptoms  may  develop  with  fibrillary  twitehings 
of  the  tongue  and  motor  impairment  of  the  labioglossopharyngeal 
muscles. 

In  the  cerebellar  form  of  Friedreich's  disease  (Monne-Marie  type) 
the  patellar  tendon  reflexes  may  be  exaggerated  and  talipes  is  absent. 
There  is  vertigo  and  general  incoordination  of  movements  which  improve 
or  disappear  when  the  patient  is  recumbent.  There  are  marked  ocular 
symptoms.  The  pupils  are  unresponsive  to  light  or  accommodation, 
while  diplopia,  color-blindness,  limitation  of  visual  field,  or  amblyopia 
from  optic  atrophy,  may  be  present. 

Friedreich's  disease  is  progressive  and  incurable,  although  it  may 
remain  stationary  for  months  or  years.  The  mental  faculties  are  im- 
paired; paraplegia  becomes  complete,  with  quite  general  muscular 
atrophy ;  speech  is  lost,  and  the  child  is  helplessly  bedridden. 

The  diagnosis  is  established  by  ataxia  extending  slowly  from  the  legs 
to  the  upper  extremities  and  tongue,  talipes  and  spinal  curvature,  with 
loss  of  knee-jerk,  retained  cutaneous  sensation,  and  developing  para- 
plegia.   No  treatment  is  of  any  known  benefit. 

landry's  paralysis — acute  ascending  paralysis. 

Landry's  paralysis  is  rare  in  childhood.  The  etiology  is  unknown. 
Although  it  has  been  commonly  classed  with  the  spinal  affections,  insuffi- 
cient proof  of  a  common  spinal  lesion  exists.  A  micrococcus  has  been 
isolated  which  produced  in  a  rabbit  rapidly  spreading  palsy.  An 
identical  organism  was  subsequently  recovered  from  the  dura  of  the 
rabbit. 

Landry's  paralysis  has  been  known  to  follow  exposure  to  cold  and 
acute  infectious  diseases.  Febrile  symptoms  may  precede  the  attack, 
which  begins  in  the  legs  and  extends  upwards,  involving  successively 
every  portion  of  the  body,  extremities,  and  head,  in  a  flaccid  paralysis, 
with  loss  of  reflexes  and  anaesthesia  following  hyperesthesia.  Atrophy 
is  not  marked  nor  is  there  change  in  electrical  reaction.  The  sphincters 
are  not  involved  and  bed-sores  are  uncommon.  The  complete  involve- 
ment may  occupy  from  two  days  to  three  weeks,  and  death  may  occur 
from  failure  of  respiration,  or  the  paralysis  may  continue  for  months. 
Occasionally  improvement  begins  in  reverse  order  to  its  invasion,  and 
rarely  recovery  follows.  There  is  no  medicinal  treatment  other  than  to 
promote  comfort,  maintain  nutrition,  and  correct  faulty  elimination. 

HEREDITARY   SPASTIC   PARALYSIS — CEREBROSPINAL    PARALYSIS. 

Occasionally  there  are  seen  conditions  to  which,  the  term  hereditary 
spastic  paraplegia  is  applied.  With  few  exceptions  a  history  of  similar 
symptoms  in  one  or  more  members  of  the  family  is  obtained. 

The  characteristics  of  this  disease  are  the  presence  of  paraplegia, 
spasticity,  contractures,  increased  deep  reflexes,  without  rectal  and 
bladder  involvement,  atrophy,  or  disturbance  of  speech.  Some  of  these 
cases  also  present  ocular  and  cerebral  symptoms, — as  amaurosis,  nystag- 


474  DISEASES    OF    THE    NEEVOUS    SYSTEM 

mus,  mental  impairment,  or  idiocy.  These  are  classed  as  cerebral  or 
cerebrospinal  spastic  paraplegia. 

This  disease  is  distinct  from  Little's  disease  and  other  birth  palsies 
due  to  dystocia,  instrumental  delivery,  or  convulsions  after  birth. 

Present  knowledge  can  only  assert  that  there  seems  to  be  an  inherent 
weakness  in  the  nervous  system  that  is  unequal  to  more  than  a  few 
years  of  normal  function. 

LOCOMOTOR   ATAXIA TABES   DORSALIS. 

Locomotor  ataxia  may  occur  in  children  born  of  syphilitic  parents. 
A  number  of  cases  have  been  reported  in  children,  between  five  and  six- 
teen years  of  age,  in  which  the  symptoms  and  lesions  were  similar  to 
those  found  in  the  adult.  The  patients  all  had  histories  of  parental 
syphilis. 

MULTIPLE   SCLEROSIS — DISSEMINATED   SCLEROSIS;    INSULAR   SCLEROSIS. 

Multiple  sclerosis  is  a  disease  the  first  symptoms  of  which  appear 
between  the  ages  of  ten  and  twenty-five  years,  although  a  number  of 
cases  have  been  observed  in  infancy  and  some  even  at  birth.  It  is  char- 
acterized by  a  more  or  less  definite  set  of  symptoms, — as  intention  tremor, 
difficult  enunciation,  ocular  symptoms  and  peculiar  gait, — although 
many  variations  are  seen. 

Etiology. — Neurotic  heredity  is  considered  a  predisposing  factor. 
Acute  infectious  diseases,  metallic  poisons,  exposure  to  cold,  shock, 
fright,  and  trauma  are  reported  as  exciting  causes.  "Whether  or  not 
irritating  substances  in  the  blood  cause  extravasation  of  toxic  lymph 
into  the  surrounding  nerve-tissue,  resulting  in  degeneration  of  the 
myelin  sheaths  of  the  nerves,  is  not  at  present  proven.  Examina- 
tions of  the  blood  have  failed  to  detect  corpuscular  alteration  or  micro- 
organisms. 

Pathology. — As  the  name  suggests,  the  lesions  consist  of  areas  or 
patches  of  sclerosis  irregularly  disseminated  throughout  the  central  ner- 
vous system,  as  well  as  the  roots  of  spinal  and  cranial  nerves.  Al- 
though the  process  involves  many  nerve-sheaths,  only  a  few  nerve-fibres 
are  totally  destroyed.  As  a  rule  the  white  substance  is  involved  to  the 
greater  extent,  and  for  this  reason  involvement  of  the  cord  has  shown 
greater  motor  than  sensory  disturbances. 

Symptoms. — The  gradual  onset  of  this  disease  is  first  indicated  by 
weakness  of  the  upper  or  lower  extremities,  with  trembling  awkwardness 
of  fingers  on  movement.  An  early  symptom  which  continues  throughout, 
is  an  "intention  tremor,"  which  occurs  upon  voluntary  effort  at  fine 
co-ordination, — such  as  writing,  tying  a  knot,  passing  a  glass  of  water, 
or  protruding  the  tongue.  The  speech  is  slow  and  the  words  are  pro- 
nounced with  care,  while  the  consonants  I,  p,  g  and  r  are  indistinctly 
enunciated.  There  may  be  inequality  of  the  pupils  with  imperfect 
reaction  to  light  and  accommodation.  Horizontal  or  vertical  nystagmus 
may  appear  if  the  eyes  be  directed  sharply  to  the  right,  left,  or  up- 


PROGRESSIVE  MUSCULAR  ATROPHY        475 

wards.  The  visual  field  may  be  narrowed  as  in  hysteria.  This  may  be 
unilateral  or  bilateral.  In  a  good  percentage  of  cases  <-;irly  changes  in 
the  retinal  papillae  are  observed  which  show  a  gray  discoloration  of  the 
entire  disk.  The  ophthalmoscope  reveals  this  optic  atrophy  and  aids 
in  diagnosis.  A  peculiar,  vague,  or  stupid  expression  pervades  the  coun- 
tenance. The  mind  seems  weakened  and  the  child  is  emotional.  Spastic 
paralysis  gradually  develops  in  the  extremities,  the  gait  becomes  stiff 
and  awkward,  and  the  deep  reflexes  exaggerated.  There  is  no  muscular 
atrophy,  no  reaction  of  degeneration,  and  in  many  cases  no  loss  of  control 
of  anal  or  vesical  sphincters.  Babinski's  and  Oppenheim's  signs  are 
present.  Bulbar  symptoms  may  supervene,  and  labioglossopharyngeal 
or  laryngeal  involvement,  with  interference  in  mastication,  deglutition, 
and  even  respiration,  may  complete  the  picture  of  functional  demor- 
alization. The  age,  the  intention  tremor,  the  nystagmus,  exaggerated 
knee-jerk,  and  spastic  gait  with  optic  atrophy,  make  up  a  group  of 
symptoms  which  cannot  be  mistaken  for  any  other  disease.  Many  years 
may  elapse  before  the  patient  dies  of  some  intercurrent  disease.  This 
disease  is  noted  for  its  periods  of  remission,  and  even  temporary  im- 
provement, but  recovery  is  hardly  possible. 

Treatment. — In  view  of  the  prognosis,  nothing  but  palliative  treat- 
ment is  indicated.  Above  all,  is  moderate  rest  for  the  tired  muscles  and 
massage  for  the  spastic  limbs.  "Warm  baths  contribute  to  the  child's 
comfort,  but  drugs  are  of  no  avail.  These  cases,  however,  should  never 
be  put  to  bed  for  any  length  of  time,  but  should  receive  a  moderate 
amount  of  exercise  daily. 

PROGRESSIVE    MUSCULAR   ATROPHY HAND   TYPE    OF   ARAN   AND    DUCHENNE ; 

LEG    TYPE    OF    CHARCOT-MARIE-TOOTH     (PERONEAL    FORM)  ;      MUSCU- 
LAR ATROPHY  WITH  PSEUDOHYPERTROPHY;     JUVENILE  FORM 
(ERB'S   TYPE)  ;     FACIO-SCAPULO-HUMERAL    (LANDOUZY- 
DEJERINE   TYPE). 

Until  recently  the  term  progressive  muscular  atrophy  was  employed 
to  describe  several  diseases,  all  of  wThich  showT  progressive  loss  of  power 
and  ultimate  atrophy  of  some  muscles,  and  all  probably  hereditary  or 
familial  in  character. 

The  first  class  begins  in  the  extremities,  usually  in  the  hand  (Aran- 
Duchenne  type)  as  a  wasting  of  the  thenar  and  hypothenar  eminences. 
The  interossei  are  next  involved,  followed  by  atrophy  of  the  forearm, 
flexors  and  extensors,  resulting  in  "claw-hand"  from  resultant  con- 
tractures. Occasionally  the  atrophic  process  gradually  extends  to  the 
muscles  of  the  arms,  shoulder,  back  and  trunk.  Rarely  the  order  of 
invasion  may  be  reversed.  One  of  the  earliest  symptoms  is  fibrillary 
twitchings  of  the  muscles  involved.  With  a  slight  irritant,  as  a  rap  on 
the  muscle,  a  tremor  and  wave  of  motion  is  set  up  that  continues  for 
some  time.  There  is  altered  response  to  faradic  and  galvanic  stimuli, 
advanced  cases  giving  the  reaction  of  degeneration.  Sensation  is  not 
impaired,  but  the  deep  reflexes  are  diminished  or  lost.     The  principal 


476  DISEASES    OF    THE    NERVOUS    SYSTEM 

spinal  lesions  are  seen  in  atrophy  of  the  ganglion  cells  of  the  anterior 
horns,  and  later  of  the  motor  nerve-roots.  It  shows  distinct  heredity 
and  frequently  begins  before  puberty. 

The  diagnosis,  from  atrophy  due  to  other  causes,  is  made  by  the 
characteristic  course,  beginning  with  the  small  muscles  of  the  hands, 
the  "individualization"  of  the  atrophy, — i.e.,  selecting  some  muscles 
and  avoiding  others  in  close  proximity ;  the  slow  progress ;  the  fibrillary 
twitchings,  and  absence  of  pain  or  loss  of  control  of  the  sphincters. 

The  prognosis  for  recovery  is  unfavorable,  although  the  course  may 
be  very  slow,  lasting  many  years.  Death  usually  results  from  some 
intercurrent  disease. 

The  treatment  is  symptomatic.  Massage  and  electrical  treatment  may 
arrest  the  atrophy. 

In  the  second  class  the  disease  may  begin  in  the  lower  extremities 
(peroneal  form  of  Charcot-Marie-Tooth),  in  which  the  extensor  muscles 
of  the  toes  first  show  weakness,  next  the  small  muscles  of  the  foot,  after 
which  the  leg  muscles  are  slowly  involved  in  the  atrophy.  The  result 
is  seen  in  deformities  of  contracture,  pes  equino-varus,  or  double  club- 
foot. 

Usually  the  first  symptoms  are  seen  in  childhood,  and  there  is  a  his- 
tory of  the  same  affection  in  several  members  of  the  family,  or  extending 
through  three  or  four  generations. 

In  this  form  also  there  are  fibrillary  twitchings,  although  these  may 
not  be  so  pronounced  as  in  the  hand  type.  Response  to  galvanic  and 
faradic  tests  is  light  or  entirely  absent.  The  tendon  reflexes  are  lost. 
Paresthesia  and  pain  may  be  present  but  there  is  no  disturbance  of  the 
sphincters. 

This  type  is  probably  confined  in  most  cases  to  the  muscles  and 
nerves,  not  involving  the  ganglion  cells  in  the  anterior  horns  of  the  cord. 
Hypertrophy  or  pseudohypertrophy  is  rarely  if  ever  seen,  although  occa- 
sionally individual  fibres  show  overgrowth.  The  disease  is  incurable. 
The  deformities  are  those  of  contracture,  some  of  which  have  been 
mentioned. 

A  third  class  of  progressive  muscular  atrophy  is  represented  by  the 
disease  long  known  as  pseudohypertrophic  paralysis,  in  which  there  is 
marked  wasting  in  some  muscles  or  groups,  with  apparent  or  real  hyper- 
trophy; in  others,  however,  atrophy  in  a  later  stage.  All  the  affected 
muscles,  whether  primarily  shrunken  or  enlarged,  are  weakened.  The 
most  marked  form  of  pseudohypertrophy  is  seen  in  the  enormous  en- 
largement of  the  calves  of  the  legs,  coincident  with  atrophy  of  the 
thigh,  back,  shoulder,  and  arm  muscles  (Fig.  176).  The  muscles  of  the 
arms,  neck,  back,  chest,  and  pelvis  may  show  atrophy  with  pseudo  (or 
real)  hypertrophy  of  the  deltoids,  the  supraspinati  and  infraspinati 
(Erb's  juvenile  type). 

Again,  the  atrophy  may  show  first  in  the  face,  extending  to  the 
shoulders  and  arms  (the  facioscapulohumeral  type  of  Landouzy-De- 
jerine),  during  the  early  part  of  which  certain  muscles  appear  normal 


PROGRESSIVE  MUSCULAR  ATROPHY 


477 


or  slightly  hypertrophied,  as  the  flexors  of  the  hand  and  forearm,  the 
scapular  muscles,  and  the  lips.  The  prominence  or  drooping  of  the  lower 
lip  (bouche  de  tapir),  with  the  paresis  of  the  orbicularis  palpebralis, 
constitute  the  fades  myopathique  of  French  authors  (Fig.  177). 

In  these  and  other  forms  of  mixed  atrophic  muscle  groupings  there 
are  no  fibrillary  twitchings,  and  the  electrical  reactions  are  but  slightly 
affected  until  late  in  the  disease,  after  extreme  atrophy.  The  mass  of 
evidence  goes  to  prove  they  are  non-spinal  in  origin.     They  are  myo- 


Fig.  176.— Pseudohypertrophic  muscular  paralysis, 
showing  large  calves,  weak  flanks,  and  atrophied 
shoulder  muscles.    (Dr.  G.  W.  Hall.) 


Fig.  177.— Progressive  muscular  dystrophy  (Lan- 
douzy-Dejerine  type).    (Dr.  G.  W.  Hall. ) 


pathic  in  distinction  from  the  amyotrophic  of  spinal  form.  The  variety 
of  these  myopathies  has  led  to  the  use  of  the  term  muscular  dystrophics 
as  best  expressive  of  the  diseases  in  which  atrophy,  with  or  without 
associated  hypertrophy,  begins  in  the  muscles  themselves,  the  later  nerve- 
and  spinal  cord  changes  being  regarded  as  secondary. 

Hereditary  etiology  is  marked  in  these  muscular  dystrophies.  They 
begin  in  infancy  or  childhood  (although  an  adult  form  is  seen),  usually 
with  weakness  of  locomotion,  fatigue  after  slight  exertion,  waddling 
gait,  and  inability  to  climb  stairs,  especially  noticeable  in  the  lower 


478  DISEASES    OF    THE    NERVOUS    SYSTEM 

limb  type.  The  characteristic  phenomena  are  seen  in  the  effort  of  the 
patient  to  rise  from  the  prone  position  ("climbing'  the  legs"  as  it  is 
called),  thus  supplementing  the  weakness  of  the  back,  hip,  and  thigh 
muscles  with  arm  strength  (Figs.  178  to  185).  Inspection  of  the  erect 
pose  shows  lordosis  and  broad  base,  with  large  calves,  in  marked  con- 
trast with  thigh,  pelvis,  trunk,  and  shoulder  muscles,  which  show  various 
degrees  of  atrophy  (Fig.  176).  So,  too,  in  the  Erb  type,  the  enormous 
deltoids  and  spinati  tower  above  the  wasted  arm,  chest,  and  back  muscles, 
while  efforts  to  elevate  the  arm  by  making  the  hand  climb  up  the  back 
of  the  neck  and  head  are  dramatic  evidences  of  loss  of  power. 

No  pain  accompanies  these  muscular  dystrophies.  There  is  a  steadily 
progressive  atrophy  until  many  muscles  are  involved,  producing  in  the 
course  of  years  complete  helplessness.  Occasionally  the  tongue  and 
muscles  of  deglutition  become  involved,  but  death  is  usually  due  to  in- 
tercurrent disorders,  especially  of  the  chest,  owing  to  superficial  breath- 
ing. The  disease  is  incurable,  although  rest  with  massage  and  electricity 
to  affected  muscles  retards  its  progress. 

The  orthopaedic  surgeon  can  do  much  to  relieve  the  deformities  as  in 
the  spinal  forms  of  paralysis. 

MULTIPLE   NEURITIS. 

Neuritis  is  a  term  applied  to  inflammation  or  acute  degeneration  of 
peripheral  nerves.  It  may  be  caused  by  blows,  prolonged  pressure  over 
a  nerve  trunk,  cold,  or  by  toxic  agents  circulating  in  the  blood, — as 
lead,  arsenic  or  alcohol.  Arsenic  from  wall  paper  and  artificial  flowers, 
lead  from  foil-wrapped  bonbons,  water  conveyed  through  lead  pipes, 
and  foods  in  soldered  tins,  are  but  a  few  of  the  many  means  by  which 
these  minerals  may  reach  the  circulation.  Arsenic  administered  for 
a  long  time  in  moderate  doses  may  produce  multiple  neuritis.  The 
alcoholic  form,  from  the  reprehensible  custom  of  giving  beer  and 
wine  to  small  children,  is  not  so  rare  in  childhood  as  was  formerly 
supposed. 

Neuritis  occurs  most  frequently  in  childhood  during  the  course  of,, 
or  as  a  sequel  to,  the  acute  infections, — as  influenza,  typhoid  and  scarlet 
fevers,  malaria  and  rheumatism,  but  especially  diphtheria. 

The  pathology  of  polyneuritis  does  not  differ  from  that  seen  in  the 
adult.  The  process  may  be  a  perineuritis,  an  interstitial  neuritis,  or 
the  inflammation  may  involve  the  parenchyma  with  degeneration  of  the 
nerve-fibre. 

For  some  reason  the  circulating  toxins,  whether  inorganic  or  bac- 
terial, show  earliest  preference  for  the  musculospiral  nerve  in  the  upper, 
and  for  the  peroneal  nerve  in  the  lower  extremities,  so  that  the  muscles 
of  those  distributions  are  usually  the  first  affected,  causing  the  familiar 
drop-wrist  and  foot.  The  most  notable  exception  is  seen  in  postdiph- 
theritic neuritis,  which  first  appears  in  paresis  of  the  palate  and  pharynx. 
Beginning  in  the  extremities  the  motor  and  sensory  disturbances  may 
extend  to  any  or  many  of  the  peripheral  mixed  nerves,  though  the  post- 


Pseudohypertrophic  muscular  paralysis.     Eighl   characteristic  postures 
assumed  in  rising  from  the  floor.     (Dr.  <!.  W.  Hall.) 


Fig.  178 


Fig.  179 


Fig.  184 


Fig.  185 


MULTIPLE    NEURITIS  47!) 

diphtheritic  neuritis  follows  a  somewhat  exceptional  course.  (See  Diph- 
theria.) 

Symptoms. — Characteristic  of  multiple  neuritis  is  the  association  of 
motor,  sensory,  and  trophic  disturbances,  symmetrically  distributed, 
with  resultant  flaccid  paralysis  and  diminution  or  absence  of  tendon 
reflexes  and  electric  excitability.  It  may  be  confined  to  a  few  muscles 
in  the  extremities  or  involve  all  the  limbs  of  the  body  in  complete  motor 
and  sensory  paralysis.  The  head,  eyes,  and  tongue  usually  escape.  The 
sphincters  ani  and  vesica?  are  exempt.  The  onset  may  be  acute,  but  is 
usually  gradual.  For  several  days  it  may  be  observed  that  the  child 
does  not  use  his  hands  accurately.  He  drops  things  and  shows  loss  of 
power,  stumbles  in  walking,  does  not  sit  erect,  or  evinces  pain  and  ten- 
derness on  being  handled,  usually  the  first  indication  in  young  infants. 
Drop-wrist  or  foot  may  appear,  accompanied  by  tenderness  over  the 
course  of  the  nerve  supplying  the  affected  muscles.  An  acute  onset  may 
be  accompanied  by  fever  and  rapid  development  of  paralysis  in  a  few 
days.  The  usual  course  is  a  gradual  development  of  paralysis  for  three 
or  four  weeks,  the  pain  and  tenderness  being  most  marked  in  the  early 
stage,  to  be  followed  by  anaesthesia  of  the  affected  areas.  After  a  month, 
or  in  less  time,  improvement  begins  in  restored  sensation,  and  proceeds 
slowly,  usually  to  complete  recovery,  although  death  may  occur  from 
cardiac  or  respiratory  paralysis.  Permanent  flaccid  paralysis  in  some 
member  occasionally  persists,  with  complete  reaction  of  degeneration. 
Electrical  tests  are  of  prognostic  value  as  to  the  outcome  of  the  attack. 
Pneumonia  in  complication  is  to  be  dreaded. 

Diagnosis. — From  acute  anterior  poliomyelitis  the  diagnosis  is  at 
times  difficult.  The  symmetrical  character,  the  gradual  onset,  the  per- 
sistence of  tenderness  or  even  pain  over  the  affected  nerve-tracts,  and 
the  existence  of  a  cause,  when  determinable,  will  aid  in  clearing  up 
doubtful  cases.  Obstetrical  and  other  forms  of  traumatic  neuritis  show 
asymmetry  and  frequently  the  cause  is  evident. 

Treatment. — Remove  the  cause,  if  possible,  whether  it  be  lead,  arsenic, 
alcohol,  or  malaria.  The  child  must  be  kept  in  bed.  For  the  pain,  dry 
heat  may  be  sufficient,  but  as  anaesthesia  develops  care  must  be  taken 
not  to  burn  or  blister  the  skin,  as  obstinate  lesions  may  be  induced. 
Warm  baths  may  quiet,  or  bromide  and  even  chloral  may  be  necessary 
to  induce  sleep.  Codeine  may  be  given  in  extreme  cases,  but  the  opiates 
should  be  withheld  if  possible.  Gentle  massage  with  fat  inunctions  com- 
fort the  patient  and  promote  the  nutrition  of  atrophied  muscles.  For 
obvious  reasons  arsenic  should  be  withheld.  Resultant  deformities  from 
contractures  may  require  orthopaedic  appliances. 

(Obstetric  Paralysis,  see  Part  II,  Chapter  I. 


CHAPTER  XII 
DISEASES  OF  THE  GLANDS,  BLOOD,  BONES  AND  JOINTS 

LYMPHATISM 

The  term  iymphatism  carries  with  it  a  suggestion  of  the  areas  and 
tissues  pathologically  involved.  It  is  preferred  to  the  older  terms, 
scrofula  or  struma,  formerly  employed  to  express  not  only  the  same  con- 
dition but  also  conditions  which  have  been  demonstrated  beyond  ques- 
tion as  tuberculous.  Since  some  writers  have  found  it  necessary  to  dif- 
ferentiate between  tubercular  and  nontubercular  scrofulosis,  it  would 
seem  that  much  that  is  vague  and  obsolete  regarding  both  the  diathesis 
and  the  infection  might  be  eliminated  from  our  literature  by  dropping 
the  term  scrofulosis.  In  its  place  Iymphatism  may  be  used,  with  proper 
adjectives,  to  express  a  wide  range  of  varying  degrees  of  disturbance, 
both  structural  and  functional,  from  the  slightest  invasion  of  the  nar- 
row border  which  separates  the  pathologic  from  the  physiologic,  during 
the  active  metabolism  of  the  developing  period,  to  the  most  pronounced 
expressions  of  a  diathesis,  whether  hereditary  or  acquired. 

The  commonest  expression  of  Iymphatism  is  seen  in  the  sensitiveness 
to  infection  of  the  lymph  nodes  of  the  mucous  and  tegumentary  areas 
which  their  channels  drain.  There  is  also  a  marked  tendency  to  hyper- 
trophy of  lymphoid  tissue,  not  only  in  the  nodes  but  in  the  adjacent 
mucosa.  Attacks  of  acute  local  catarrh  establish  a  predisposition  to  its 
recurrence,  so  that  the  case  soon  develops  into  that  of  a  catarrhal  condi- 
tion, with  a  history  of  repeated  acute  exacerbations.  The  adjacent  lymph 
nodes  in  the  earlier  history  show  alternate  engorgement  and  subsidence 
with  each  wave  of  infection.  Later,  these  nodes  show  permanent  enlarge- 
ment with  induration  and  hyperplasia  of  their  structure.  The  lymphoid 
bodies  in  the  mucosa  hypertrophy  with  increase  in  their  tissue  elements, 
both  connective  and  vascular.  This  is  most  frequently  seen  in  the 
lymphoid  ring  of  the  oronasopharynx,  the  bronchial  glands  and  those 
of  the  alimentary  tract. 

It  has  been  claimed  that  the  constitutio  lymphatica  is  normal  to 
infancy  and  early  childhood.  Without  concurrence  in  this  statement, 
it  is  true  that  it  is  during  the  developing  period  that  Iymphatism  is 
commonly  seen.  Two  clinical  pictures  representing  types  of  this  con- 
dition are  familiar :  First,  the  phlegmatic,  torpid  lymphatic  type.  These 
children  are  usually  pale,  fat,  and  flabby,  and  show  general  glandular 
enlargements  which  persist,  especially  those  in  the  neck.  The  adenitis 
becomes  chronic,  with  increasing  frequency  in  acute  exacerbations,  each 
480 


LYMPIIATLSM  481 

of  which  increases  the  nodular  induration.  The  chronic  catarrhs  of  the 
adjacent  mucosas  intensify  this  condition.  These  children  are  pecu- 
liarly susceptible  to  pyogenic  processes,  while  otorrhcea,  bronchorrhcea, 
and  purulent  discharges  from  all  the  areas,  with  tegumentary  and 
phlegmonous  suppurative  softening  and  destruction  of  tissues,  leaving 
livid  cicatrizations,  complete  the  picture.  Second,  the  neuro-sanguine 
lymphatic,  of  spare  habit  and  precocious  mentality,  in  which  the  external 
lymph-nodes,  although  quickly  responding  to  local  infections,  do  not 
show  a  tendency  to  marked  hyperplastic  induration.  The  deeper  nodes, 
however,  as  the  bronchial  and  enteric,  from  repeated  recurrences  of 
bronchitis  and  enteritis,  show  persistent  hypertrophy  with  ever-threaten- 
ing bronchopneumonia  and  enteritis  of  severe  type,  which  keeps  the  phy- 
sician on  the  alert  for  pulmonary  and  intestinal  tuberculosis. 

Growth  is  usually  retarded,  leaving  the  survivors  stunted  in  child- 
hood and  undersized  in  maturity. 

The  occurrence  of  sudden  and  unexplained  death  in  the  subjects  of 
lymphatism  has  led  to  a  line  of  inquiry  with  the  following  anatomic 
findings:  There  is  a  tendency  to  a  persistence  or  even  hypertrophy  of 
the  thymus  which,  in  some  instances,  is  so  obvious  as  to  cause  substernal 
■dulness  on  percussion.  Sometimes  this  enlargement  is  regarded  as 
sufficient  cause  of  death  from  mechanical  pressure  on  the  pneumogastric 
nerve,  heart,  or  the  arch  of  the  aorta.  Since  in  many  of  these  cases 
the  fatal  syncope  occurred  during  extreme  cervical  extension,  causing 
unusual  pressure  on  substernal  structures,  the  cause,  not  unnaturally, 
was  attributed  to  the  large  thymus  and  sometimes  to  the  hypertrophied 
thyroid.  In  this  connection  the  so-called  thymic  asthma,  presumably 
due  to  pressure  of  an  exceptionally  large  gland  upon  the  recurrent 
laryngeal  nerve,  is  a  not  infrequent  accompaniment  of  the  status  lym- 
phaticus. 

The  before-mentioned  enlargement  of  the  bronchial-nodes  which,  at 
times,  causes  marked  tumefactions  at  the  bifurcation  and  roots  of  the 
larger  bronchi,  plays  an  important  part  in  this  tendency  to  substernal 
pressure,  aggravated  by  the  dorsal  decubitus  with  head  retraction. 

Recent  study  of  these  cases  has  shown  not  only  hyperplasia  of  the 
lymph-nodes,  thymus,  and  spleen,  but  also  hypoplasia  of  the  heart  and 
aorta,  so  that  the  conclusion  is  not  unreasonable  that  the  causes  of  fatal 
syncope  are  due  to  defects  of  the  cardiovascular  structures  themselves. 
Whatever  may  be  the  relative  etiologic  value  of  these  glandular  and 
vascular  conditions,  the  diagnosis  of  status  lymphaticus  has  recently 
served  as  an  explanation  in  the  quest  of  cause  for  sudden  death  in  infants 
of  this  type. 

The  importance  of  its  recognition  is  apparent  when  the  question  of 
anesthesia,  operation,  or  any  procedure  likely  to  produce  shock,  is  under 
consideration. 

Although  the  largest  proportion  of  cases  of  lymphatism  is  due  to 
heredity,  it  occasionally  appears  as  a  familial  type  where  neither  parents 
have  suffered  from  lymphatism,  tuberculosis,  or  rheumatism.     Again, 

31 


482  DISEASES    OF    THE    GLANDS 

lymphatism  may  develop  in  an  infant  previously  free  from  dyscrasia, 
with  a  good  family  history,  after  an  acute  infectious  disease, — such  as 
measles,  scarlet  fever,  pertussis,  or  influenza. 

It  has  long  been  believed  that  malhygiene  is  important,  both  as  a 
predisposing  and  as  an  exciting  cause.  The  crowded  tenement-houses 
of  cities  furnish,  by  far,  the  greatest  number  of  cases. 

The  treatment  is  essentially  hygienic  and  nutritional.  These  chil- 
dren should  have  fresh  air  in  abundance,  preferably  at  the  seashore, 
protection  from  sudden  lowering  of  the  body  temperature,  removal  of 
adenoids,  and  treatment  of  local  catarrhs.  Iodine  and  the  iodides  are 
almost  always  indicated,  especially  the  iodide  of  iron  for  the  anaemia 
which  is  usually  present.  The  hydrocarbons,  especially  cod-liver  oil, 
are  as  valuable  to-day  as  during  the  past  century.  Where  oil  is  not 
well  tolerated  by  the  stomach,  much  benefit  may  be  derived  from  daily 
inunctions  and  thorough  massage  with  cod-liver  oil  or  with  a  mixture 
of  animal  and  vegetable  fats,- — as  peanut,  cocoanut,  olive,  beef  suet,  and 
wool  fat. 

Although  lymphatism  is  amenable  to  treatment,  and  in  uncompli- 
cated cases  the  prognosis  is  favorable,  the  undeveloped  condition  of  the 
heart  and  arteries,  with  the  predisposition  to  fatality  from  otherwise 
insignificant  causes,  must  not  be  forgotten.  Many  deaths  from  inter- 
current disorders- — as  measles,  scarlet  fever,  and  diphtheria — are  un- 
doubtedly due  to  this  condition.  The  marked  predisposition  to  tuber- 
cular processes  before  that  infection  was  so  well  understood,  attached 
to  scrofula  a  graver  prognosis  than  its  uncomplicated  state  deserves. 

SIMPLE   ACUTE   ADENITIS. 

The  terms  simple  or  idiopathic  adenitis  do  not  seem  to  harmonize 
with  the  present  knowledge  of  infectious  processes.  Swelling,  hyper- 
trophy, and  hyperplasia  of  the  lymph  nodes,  with  or  without  necrosis, 
is  so  frequently  attributable  to  microbic  invasion  that  it  is  difficult  to 
conceive  of  such  a  thing  as  simple,  idiopathic,  or  non-infectious  adenitis. 
For  the  same  reason  many  object  to  the  term  primary  adenitis,  which 
they  claim  is  merely  a  confession  of  the  inability  to  locate  the  initial 
lesion  or  port  of  entry  of  the  microbe  or  toxin  which  excites  the  adenitis. 
Possibly  the  only  exception  to  microbic  origin  is  seen  in  the  not  un- 
common occurrence  of  enlargement  of  lymph-nodes  following  unusual 
or  prolonged  exercise  of  the  muscles, — as,  for  instance,  the  enlarged 
inguinal  glands  at  the  beginning  of  skating  or  running,  and  the  axillary 
enlargements  of  the  young  ball-player. 

The  term  lymphadenitis  is  applied  to  all  lymph  nodes  that  are  de- 
monstrably enlarged.  Although  no  age  affords  immunity,  it  is  pecu- 
liarly an  affection  of  the  developing  period.  In  clinical  description  it 
is  convenient  to  speak  of  adenitis  as  acute  and  chronic,  the  former  as  an 
accompaniment  of  all  the  acute  catarrhal  lesions,  including  the  acute 
infectious  diseases.  Chronic  adenitis  seems  to  be  the  common  condition 
in  childhood  to  which  there  are  few  exceptions. 


SIMPLE    ACTTE    ADENITIS  483 

Palpable  glands,  especially  in  the  neck,  are  the  rule  in  children  in 
institutions  and  in  those  who  throng  the  dispensaries.  Nor  does  private 
practice  among  the  well-to-do  class  show  marked  exemption  from  this 
widely  prevalent  condition.  It  may  be  that  the  wide  prevalence  of 
catarrhal  conditions,  influenced  largely  by  the  climatic  peculiarities  of 
the  lake  region,  may  make  these  conclusions  exceptional  to  those  formed 
from  observations  in  a  more  stable  climate. 

Although  acute  adenitis  may  develop  in  any  lymphatic  gland  of  the 
body,  its  most  frequent  occurrence  is  in  the  cervical  lymph-nodes,  both 
anterior  and  posterior  to  the  sternomastoid  muscles,  beneath  the  angle  of 
the  jaw  and  under  the  chin  (Fig.  186). 

As  a  rule  acute  adenitis  is  rarely  diagnosed  as  such,  and  is  seldom 
brought  to  the  physician  for  that  condition  alone.     It  is  usually  for 


Fig.  186. — Acute  cervical  adenitis. 


the  mouth,  throat,  nasopharynx,  or  ear  affections  that  the  physician  is 
called,  the  acute  adenitis  constituting,  therapeutically  as  well  as  etio- 
logically,  a  secondary  matter.  Rarely  the  child  is  brought  to  the  physi- 
cian for  a  lump  in  his  neck  which  was  not  there  at  the  time  of  last 
bathing,  with  no  history  of  antecedent  infection.  Examination,  how- 
ever, seldom  fails  to  reveal  the  remains  of  an  acute  aural,  faucial,  or 
nasopharyngeal  disturbance.  The  nodes  affected  may  be  unilateral  or 
bilateral,  generally  showing  first  on  one  side,  and  with  different  degrees 
of  involvement.  Rarely  a  single  gland  is  affected,  the  enlargement 
usually  showing  in  a  group  of  nodules  which  may  be  separately  outlined 
and  which  are  freely  movable.  It  occasionally  occurs,  however,  that  a 
large  group  swells  simultaneously,  as  in  a  bunch,  with  much  peri- 
glandular infiltration,  forming  a  tumor  in  which  the  separate  nodes  are 
indistinguishable  and  over  which  the  integument  may  be  tense  and 
shining.     Palpation  reveals  tenderness  which  is  occasionally  marked, 


484  DISEASES    OF    THE    GLANDS 

although  unprovoked  pain  is  rarely  a  feature.  The  feel  in  these  acute 
cases  is  usually  boggy  but  occasionally  highly  elastic.  The  skin  is 
rarely  adherent  and  the  glands,  unless  there  is  much  infiltration,  are 
movable. 

The  course  of  the  adenitis  depends  largely  upon  the  nature  of  the 
infectious  microbe,  although  in  this  connection  the  individual  resist- 
ance cannot  be  overlooked.  Infection  from  pyogenic  organisms — e.g., 
staphylococcus  and  streptococcus — may  lead  to  suppuration  and  break- 
ing down  of  the  glands  and  the  adjacent  cellular  tissues  with  pus 
burrowing,  in  neglected  cases.  The  necrotic  process  may  be  accom- 
panied by  hemorrhages.  This  occurrence,  it  is  claimed,  is  most  fre- 
quently due  to  infection  by  the  diphtheria  bacillus.  Necrosed  areas, 
when  limited  to  the  substance  of  the  gland,  may  be  enclosed  by  increased 
connective  tissue  growth  with  resorption  of  all  but  the  calcareous  ma- 
terial, which  is  occasionally  found  as  a  result  of  an  old  suppurative 
lesion.  The  abscess  may  point  on  the  surface  and  discharge  without 
the  aid  of  surgical  interference.  Suppuration  may  be  present,  with- 
out discharge,  the  small  amount  of  pus  being  absorbed.  Suppura- 
tion, however,  is  not  the  rule  in  acute  adenitis.  The  swelling  of  the 
nodes  that  follows  the  acute  lesion  in  from  two  to  four  days  subsides 
gradually  in  from  one  to  three  weeks.  There  is  usually  elevation  of 
temperature,  which  subsides  with  the  disappearance  of  the  primary  in- 
fection. 

In  some  acute  infectious  diseases — as  diphtheria  and  scarlet  fever — ■ 
the  extensive  glandular  and  periglandular  involvement  from  the  primary 
angina  may  be  maintained  for  a  considerable  time  by  the  sequelae  of 
nasal,  faucial,  pharyngeal,  or  aural  extension. 

Acute  adenitis  of  the  inguinal  glands  frequently  accompanies  vulvo- 
vaginitis in  girls,  and  preputial  or  urethral  lesions  in  boys.  They  may 
also  be  due  to  any  suppurating  lesions  of  the  lower  extremities.  Abra- 
sions and  infected  lesions  of  the  upper  extremities  and  pectoral  regions 
affect  the  axillary  nodes,  a  common  occurrence  in  vaccination. 

Mesenteric  lymph-glands  show  acute  enlargement  from  intestinal  in- 
fection, as  in  ordinary  enterocolitis,  while  those  of  the  mediastinum  are 
probably  enlarged  in  all  acute  bronchial  catarrhs  and  pneumonia.  Al- 
though acute  adenitis  shows  a  tendency  to  rapid  recovery  in  the  majority 
of  cases,  the  affected  nodes  remain  permanently  enlarged  from  slight 
increase  in  the  fibrous  tissue. 

The  immediate  prognosis  is  good,  except  in  neglected  suppurative 
cases  with  extensive  burrowing  and  systemic  reinfection. 

Treatment. — Aside  from  suppurative  cases,  acute  lymphadenitis  re- 
quires but  little  treatment  beyond  that  directed  to  the  primary  affection. 
Local  applications  over  the  affected  glands,  except  for  relief  of,  pain, 
are  of  doubtful  utility.  In  this  category  may  be  placed  ice-bags,  hot 
fomentations,  poultices,  embrocations,  etc.  Since  active  phagocytosis 
requires  hyperemia,  local  depletion  may  interfere  with  the  functional 
activity  of  the  gland.     The  usual  indications  of  pus,  such  as  persistent 


HODGKIX'S    DISEASE  485 

or  irregular  fever,  with  or  without  chill,  marked  leucocytosis,  and 
fluctuation  in  the  tumor,  call  for  its  prompt  evacuation.  In  doubt- 
ful cases,  a  judicious  use  of  the  hypodermic  aspirator  will  determine  the 
location  of  a  small,  deeply  seated  abscess.  After  free  opening,  the  ab- 
scess must  be  thoroughly  drained  by  a  tent  or  wick.  Care  is  necessary 
to  prevent  too  early  closure  of  the  incision. 

CHRONIC   ADENITIS. 

Chronic  adenitis  is  a  term  used  to  express  permanent  enlargement 
of  the  lymph  nodes,  whether  as  a  result  of  a  congenital  dyscrasia — 
such  as  syphilis,  tuberculosis,  or  lymphatism — or  whether  as  a  result 
of  repeated  attacks  of  acute  adenitis. 

The  proneness  to  acute  exacerbations  in  chronically  enlarged  lymph 
nodes  is  so  well  known  to  the  physician  that  the  presence  of  numerous 
permanently  palpable  lymphatic  glands  in  the  child  affords  an  index 
of  his  susceptibility  to  infection  from  apparently  trivial  causes.  Aside 
from  syphilis  and  tuberculosis,  this  is  their  main  significance.  The 
indications  are  preeminently  those  of  improved  hygiene,  to  afford  pro- 
tection and  to  increase  the  resistance  against  infection.  Restoratives, 
as  iron  and  cod-liver  oil,  have  proved  of  clinical  value  for  the  anaemia 
and  malnutrition  of  these  cases.  The  iodides  are  claimed  to  promote 
reduction  of  the  indurated  glands,  and  iodide  of  iron  holds  a  front 
rank  in  the  therapy.  Some  claim  is  made  for  the  utility  of  persistent 
applications  of  mercurial  ointment  and  compound  iodine  solutions  over 
the  affected  nodes. 

HODGKIN'S     DISEASE — PSEUDOLEUKEMIA;     LYMPHATIC     ANEMIA;     ADENIA ; 

LYMPHADENOMA. 

The  term  Hodgkin's  disease  is  preferable  to  any  of  the  numer- 
ous names  that  have  been  proposed  as  substitutes,  because  it  is  not  mis- 
leading in  regard  to  the  etiology  or  pathology  of  the  particular  con- 
dition. 

This  disease  is  rarely  found  in  infancy,  occasionally  in  childhood, 
and  frequently  in  young  adults. 

The  earliest  and  most  noticeable  manifestations  appear  in  the  en- 
largement of  the  glands  in  the  anterior  and  posterior  cervical  regions 
(Fig.  187).  Although  bilateral,  one  side  usually  shows  greater  involve- 
ment. The  adenitis  often  is  of  slow  development,  frequently  covering  a 
period  of  one  to  three  years,  with  little  or  no  recession.  The  enlarged 
nodes  are  at  first  freely  movable,  but  later  fuse  and  form  adhesions  to  the 
overlying  integument,  presenting  painless,  doughy  nodules,  attaining 
at  times  an  enormous  size.  These  masses  show  no  tendency  to  caseate 
or  suppurate.  Glandular  enlargements  in  the  axillary  and  inguinal 
regions  are  noted  in  the  majority  of  cases,  and,  in  some,  the  bronchial 
and  mesenteric  nodes  are  found  hypertrophied.  The  respiratory  and 
alimentary  mucous  tracts  do  not  often  show  the  hypertrophic  lymphoid 
involvement. 


486  DISEASES    OF    THE    GLANDS 

Next  to  the  local  cervical  enlargements  the  most  noticeable  sign  is 
the  anaemia.  The  general  symptoms  are  those  clue  to  pressure  of  the 
glandular  masses  upon  adjacent  structures,  in  addition  to  those  due  to 
the  steadily  progressive  impoverishment  of  the  blood.  Hence,  there 
are  usually  present  dysphagia,  dyspnoea,  spasmodic  cough,  cerebral  con- 
gestion, hemorrhages,  irregular  heart  action,  muscular  atony,  and  in- 
creasing physical  weakness.  Elevation  of  temperature  is  not.  a  common 
symptom,  and  when  present  is  probably  due  to  some  accompanying  con- 
dition.    The  blood  picture  is  not  characteristic. 

The  etiology  of  Hodgkin's  disease  is  not  yet  determined.  The  belief 
is  prevalent  that  it  is  of  infectious  origin.     Roux  and  Lannois  claim 


Fig.  187.— Hodgkin's  disease.     Girl,  aged  11  years. 

to  have  reproduced  the  disease  in  lower  animals  by  the  injection  of 
a  micrococcus  from  the  blood  and  lymph-glands  of  a  patient  suffering 
from  this  disease. 

There  is  a  general  increase  in  new  lymphoid  tissue  (lymphadenitis) 
in  nearly  every  organ  of  the  body,  excepting  the  brain  and  spinal  cord. 
The  spleen  shows  more  or  less  enlargement  in  the  majority  of  cases. 
Occasionally  it  becomes  enormously  enlarged  but  retains  its  normal  shape 
(Fig.  188). 

Microscopical  examination  shows  great  proliferation  of  lymphoid 
tissue,  pushing  beyond  the  gland  capsule,  with  increase  in  connective 
tissue,  which  results  in  the  agglutination  of  the  hypertrophied  nodes  and 
adjacent  tissues  into  a  dense  mass. 

The  angemia  consists  in  more  or  less  reduction  in  the  number  of  red 
corpuscles  with  marked  diminution  of  haemoglobin,  falling,  in  some  cases, 


DISORDERS  OF   THE   SPLEEN 


487 


as  low  as  twenty  per  cent.     There  is  no  increase  in  the  neutrophils, 
although  a  marked  lymphocytosis  is  a  regular  accompaniment.      The 

diagnosis     from     leukaemia     is 
based    on    the    absence    of   the 

characteristic  blood  findings  of 
that  disease. 

In  differentiation  from 
chronic  adenitis,  the  history 
of  some  source  of  infection, 
painful  swelling,  and  ab- 
sence of  profound  anaemia,  are 
of  aid. 

Tubercular  adenitis  usually 
gives  a  history  of  rise  of  tem- 
perature, with  tendency  to 
caseous  and  suppurative  soften- 
ing of  the  hypertrophied  glands, 
accompanied  or  followed  by 
evidence  of  tuberculous  inva- 
sion of  other  organs.  The 
tuberculin  test  and  inoculation 
of  animals  would  establish  the 
presence  or  absence  of  tuber- 
culosis. 

Cases  of  Hodgkin's  disease 
have  been  reported  cured  by 
the  persistent  use  of  arsenic, 
both  by  mouth  and  by  hypo- 
dermic injections  of  the  affected 
glands.  Early  extirpation  has 
resulted  in  cures  in  a  few  in- 
stances. From  recent  favorable 
reports  the  use  of  the  X-ray 
is  worthy  of  trial,  but  must  be  carefully  employed  in  young  children. 


Fig.  188.— Hodgkin's  disease.  H.  F.,  aged  7  years. 
Red  cells,  3,715,000;  white  cells,  9,000;  liEemoglobin,  55 
per  cent.    Both  spleen  and  liver  enormously  enlarged. 


DISORDERS    OF    THE    SPLEEN. 

Disorders  in  which  signs  of  splenic  disturbances  form  part  of  the 
clinical  findings  are  more  frequent  in  childhood  than  in  later  life. 
That  few  of  these  are  primarily  of  splenitic  origin  does  not  lessen  the 
interest  in  the  part  played  by  this  organ  in  a  great  number  of  infantile 
diseases.  Acute  splenitis,  chronic  hyperplasia,  traumatisms,  and  septic 
abscesses,  are  met  with  in  childhood,  and  rarely  malignant  neoplasms, 
primary  splenomegaly,  and  hydatid  cysts  are  reported  by  examining 
physicians. 

Unlike  adrenal  decapsulation,  splenectomy  is  not  fatal  to  life.  The 
functions  of  the  spleen,  whether  digestive,  antitoxic,  or  haematopoietic, 
find   compensation   in   increased   activity   of   other   structures, — as   the 


488 


DISEASES    OF    THE    GLANDS 


lymphoid,  thyroid,  and  adrenals.  It  is  not  surprising,  therefore,  that 
death  is  rarely  attributable  to  disease  of  the  spleen  alone. 

The  spleen,  in  some  instances,  is  freely  movable  and  subject  to  dis- 
placement by  violence  or  stretching  of  its  pedicle  from  the  weight  of 
engorgement,  appearing  as  a  tumor  in  the  lower  abdomen. 

Its  peculiar  structure  and  the  relation  of  its  histological  elements 
may  explain  its  characteristic  susceptibility  to  enlargement,  as  is  seen 
in  congestion  of  the  liver  and  any  obstruction  of  portal  circulation  or 
from  obstructed  pulmonic  circulation,  as  in  extensive  pneumonia  or 
emphysema.  Likewise  this  enlargement  appears  in  cardiac  incompe- 
tency, congenital  or  acquired.  This  effect  upon  the  spleen  is  noticeable 
in  malaria,  typhoid  fever,  and  congenital  syphilis,  and,  as  a  rule,  with 
the  exception  of  the  latter,  the  symptomatic  diagnosis  is  not  complete 
in  the  absence  of  demonstrable  enlargement.  Reports  on  congenital 
syphilis  show  splenic  enlargement  in  from  twenty-five  to  forty  per  cent, 
of  all  cases.    Although  common  in  malaria  and  typhoid  fever,  the  fact 


Fig.  189.— Palpating  the  spleen. 

that  the  spleen  may  become  palpable  in  almost  all  the  acute  infections 
deprives  this  sign  of  the  pathognomonic  importance  formerly  attributed 
to  it. 

Tuberculosis  in  children  not  infrequently  shows  splenic  enlargement 
with  occasional  tubercular  lesions  in  this  organ.  Splenic  enlargement  is 
quite  common  in  rhachitis  and  not  rarely  accompanies  extreme  malnutri- 
tion from  any  cause.  Usually  this  enlargement  subsides  with  the  disap- 
pearance of  the  primary  infectious  process.  If  long  continued,  however,, 
the  organ  may  undergo  hyperplasia  and  remain  chronically  enlarged, 
or  emboli  may  result  in  abscesses,  as  in  infective  endocarditis,  pyaemia, 
etc.  Amyloid  degeneration  follows  long-continued  suppuration  or  mal- 
nutrition. 

The  spleen  may  be  ruptured  by  blows  or  falls,  with  extensive  hemor- 
rhage into  the  peritoneal  cavity.  Spontaneous  rupture  may  occur  from 
extreme  distention,  accompanying  malaria  and  typhoid  fever. 

Sarcoma  and  even  carcinoma  of  the  spleen  have  been  seen  in  child- 
hood. Cysts,  neoplasms,  and  abscesses  can  not  be  diagnosed  as  splenic, 
except  by  the  location  and  outline  of  the  tumor.     In  older  children 


DISORDERS    OF    THE    SPLEEN 


489 


sensations  of  weight  and  dragging  in  the  left  hypochondriac  region  are 
described,  following  splenic  enlargement  from  any  cause.  Acute  pain 
is  suggestive  of  perisplenitis.  Rupture  with  intraperitoneal  hemorrhage 
gives  only  the  signs  of  profound  exsanguination. 

Aside  from  treatment  of  the  primary  conditions  and  surgery,  no 
therapy  of  the  spleen  is  of  any  marked  benefit  with,  perhaps,  the  ex- 
ception of  local  galvanism. 

Much  confusion  still  exists  as  regards  both  the  etiology  and  clinical 
findings  of  a  progressive  enlargement  of  the  spleen,  known  as  splenomeg- 

alia,  splenic  anaemia,  splenic 
pseudoleukemia,  splenic  lymph- 
adenoma,  splenic  cachexia, 
lymphgemia,  and  Banti's  dis- 
ease. That  this  condition,  if  it 
be  entitled  to  consideration  as 
a  disease,  is  progressive  is  quite 
evident.  Splenic  anaemia  may 
begin  in  early  infancy  and  has 
been  known  to  continue  for 
twenty-five  years.  This  disease 
is  marked  by  the  absence  of  all 
recognized  causes  of  splenic  en- 
largement, whether  infectious 
or  obstructive.  There  are  no 
constant  blood  findings  except 
those  of  a  secondary  anaemia,, 
nor  are  the  lymph  nodes,  ex- 
ternal or  internal,  uniformly 
affected.  The  spleen  may  grad- 
ually reach  enormous  propor- 
tions, extending  as  far  as  the 
right  iliac  fossa,  with  no  local 
symptoms  save  those  due  to 
pressure  disturbances  (Fig. 
190).  Later,  hemorrhages  from 
mucous  membranes,  with  pete- 
chia? and  ecchymoses,  and  occa- 
sional pigmentation  of  the  skin, 
also  jaundice  and  ascites,  occur. 
No  procedure  has  arrested  the 
progress  of  this  disorder  save  splenectomy,  which  shows  about  seventy- 
five  per  cent,  of  recoveries. 

DISORDERS  OF  THE  ADRENALS. 

Hemorrhages. — Until  the  true  physiological  role  of  the  suprarenal 
glands  is  established  beyond  question,  the  effects  of  their  functional  or 
structural  disturbances  must  remain  unsolved  problems.     Since  death 


Fig.  190.— Herbert  0.,  aged  12  years.  Splenic  anaemia. 
Red  cells,  4.112,000;  white  cells,  2650;  haemoglobin, 
50  per  cent. ;  color  index,  .6 ;  polymorphonuclear,  84 
per  cent ;  small  mononuclear,  7  per  cent. ;  large  mono- 
nuclear, 4  per  cent. 


490  DISEASES    OF    THE    GLANDS 

follows  the  removal  of  both  glands  in  from  three  hours  to  three  days, 
independent  of  surgical  shock,  analogy  would  suggest  the  same  result 
from  any  sudden  cessation  of  their  function  from  any  cause.  This 
supposition  is  proven  in  cases  of  adrenal  apoplexy,  which  is  not  infre- 
quent in  early  infancy.  Recent  post-mortem  reports  of  sudden  deaths  in 
infancy  show  an  increasing  number  of  hemorrhages  into  the  suprarenal 
structures.  In  a  number  of  instances  the  adrenals  are  the  only  organs 
involved.  The  free  blood  supply  and  the  fragile  structure  of  the  tissue, 
aside  from  septic  conditions  of  the  blood,  may  explain  the  tendency  to 
hemorrhage  into  these  organs  under  all  conditions  which  induce  great 
intravisceral  pressure.  The  manner  of  death,  with  its  preceding  symp- 
toms, corresponds  with  remarkable  fidelity  to  those  accompanying  aboli- 
tion of  these  bodies.  The  symptoms  of  adrenal  hemorrhage  may  develop 
suddenly  and  may  be  ushered  in  by  acute  abdominal  pain,  dyspnoea, 
pallor,  weak  pulse,  cold  extremities,  followed  by  coma  or  convulsions, — 
all  indications  of  collapse.  Vomiting,  and  not  infrequently  diarrhoea, 
may  be  present.  Death  occurs  within  a  few  hours.  Adrenal  hemorrhage 
may  occur  in  the  course  of  pertussis,  bronchopneumonia,  retrocedent 
exanthems,  and  variola,  or  may  follow  convulsions  or  traumatisms — 
as  blows  or  extensive  burns — and  may  be  overlooked  and  unsuspected 
as  a  cause  of  death  until  revealed  at  the  post-mortem. 

Since  no  physical  signs  may  indicate  the  extent  of  the  involvement 
of  one  or  both  adrenals,  as  a  forlorn  hope  efforts  may  be  made  to 
restore  the  equilibrium  of  the  circulation  by  external  heat  and  the  use 
of  adrenal  extract.  As  in  other  hemorrhages,  hypodermics  of  normal 
saline  solution  are  indicated,  and  enteroclysis  of  milk  of  asafetida  for 
its  effects  upon  the  abdominal  sympathetic  nerves  may  be  given  in  proper 
quantity. 

Addison's  Disease. — In  children,  as  in  adults,  the  adrenals  are 
subject  to  degenerative  changes,  both  cystic  and  interstitial,  and  also 
furnish  the  seat  for  neoplasms,  benign  and  malignant.  All  of  these, 
from  our  present  knowledge,  act  as  etiologic  factors  in  the  progressive 
neurasthenia  known  as  Addison's  disease.  Although  rare  in  early  life, 
it  does  occur  in  infancy  and  has  been  reported  as  congenital,  as  in  a 
case  in  which  death  occurred  at  eight  weeks.  In  this  the  post-mortem 
showed  cystic  degeneration  of  both  capsules. 

This  disorder,  in  the  large  majority  of  cases,  is  probably  due  to 
tubercular  invasion  of  the  suprarenal  cortex,  and  is  usually  accompanied 
by  other  evidences  of  general  tuberculosis.  However,  there  are  cases  on 
record  in  which  autopsies  showed  tuberculous  changes  in  no  organs 
other  than  the  adrenals. 

The  disease,  as  in  adults,  is  characterized  by  progressive  muscular 
weakness  and  symptoms  of  secondary  angemia, — as  rapid  pulse,  dyspnoea, 
headache,  epigastric  pain  and  tenderness.  'Pigmentation  of  the  skin  and 
mucous  membranes  is  usually  present.  Diarrhoea  is  said  to  be  more 
common  than  later  in  life. 

Untreated,  the  disease  is  fatal  in  from  one  to  three  years,  death 


DISORDEBS    OF    THE    THYMUS  491 

resulting  from  inanition  or  some  intercurrent  disorder.  Since  hiber- 
nating animals  bear  the  loss  of  their  adrenals  better  than  those  in  active 
life,  a  hint  may  be  derived  of  value  in  treatment, — namely,  to  restrict 
muscular  exercise  to  the  lowest  point  compatible  with  life.  If  the 
disorder  be  due  to  restricted  function  through  structural  changes  in 
the  adrenal  glands,  the  administration  of  the  suprarenal  extract  is 
rational  therapy.  Transplantation  of  the  gland  from  lower  animals 
has  been  adopted,  and  the  raw  gland  or  dried  extracts  have  been  given 
with  some  success. 

Symptomatic  treatment  consists  in  measures  for  the  relief  of  general 
asthenia  and  irritability  of  the  digestive  tract  by  careful  supervision  of 
diet.  Guaiacol,  iodine,  creosote,  and  carbolic  acid  are  indicated  in  the 
double  role  of  gastric  sedatives  and  general  antitoxics. 

DISORDERS   OF   THE   THYMUS. 

The  thymus  gland  may  be  absent,  atrophied,  or  hypertrophied.  It 
may  be  the  site  of  neoplasms,  tubercular,  syphilitic,  sarcomatous,  or 
carcinomatous,  or  of  abscesses  and  cysts.  In  none  of  these  conditions 
can  more  than  a  probable  diagnosis  be  made.  Post-mortems  show 
atrophy  of  the  thymus  in  infants  dying  of  marasmus.  On  the  other 
hand,  thymectomy  is  not  necessarily  fatal.  A  vast  amount  of  experi- 
mental work  has  thus  far  failed  to  determine  the  etiologic  relation  of  dis- 
orders of  the  thymus  gland  to  other  conditions.  The  fact  that  the 
period  of  greatest  thymic  activity  is  coincident  with  that  of  most 
rapid  growth  suggests  an  intimate  association  with  the  process  of  de- 
velopment. It  is  more  than  probable  that  it  supplements  the  action  of 
the  thyroid  gland  and  with  it  exercises  a  very  positive  influence  on 
nutrition.  Cretins  fed  on  thyroid  extract  increase  rapidly  in  stature, 
but  the  bones  become  soft  and  bend  easily.  Under  thymus  extract  this 
tendency  to  bone  softening  is  said  to  disappear.  Imbecile  dwarfs  not 
cretins  have  shown  increased  rate  of  growth  under  thyroid  extract,  with 
no  sign  of  mental  improvement  until  after  the  administration  of  thymus 
extract.  In  this  connection  it  is  interesting  to  note  that  a  large  per- 
centage of  autopsies  of  imbeciles  and  epileptics  show  absence  or  atrophy 
of  the  thymus  gland.  Although  the  future  may  promise  brilliant  results 
in  thymic  therapy  our  present  knowledge  warrants  no  more  than  its 
experimental  use. 

Much  discussion  has  arisen  as  to  the  etiologic  relationship  of  an 
enlarged  thymus  in  cases  of  sudden  death  in  infancy  and  childhood. 
The  distance  from  the  manubrium  sterni  to  the  vertebral  column  is  only 
from  two  to  three  centimetres,  and  this  narrow  space  must  accommodate 
the  trachea,  oesophagus,  great  blood-vessels,  nerves,  and  muscles.  But 
little  room  is  left  for  a  normal-sized  thymus.  This  organ  is  sometimes 
found  enlarged  to  many  times  its  average  size,  with  the  result  of  great 
pressure  upon  trachea,  pneumogastric,  and  recurrent  laryngeal  nerves, 
as  well  as  upon  the  heart  and  great  vessels.  Under  these  conditions  a 
sudden  increase  of  pressure — as  from  lying  on  the  face  or  back  with 


492  DISEASES    OF    THE    GLANDS 

extreme  extension,  congestion  from  violent  fits  of  coughing  or  vomiting, 
convulsions,  and  swallowing  large  pieces  of  hard  material — would  cause 
asphyxiation,  dyspnoea,  syncope,  or  sudden  death.  Intubation  and  tra- 
cheotomy afford  but  transient,  if  any,  relief.  Resection  of  a  portion  of 
the  hypertrophied  thymus  has  been  performed  with  the  amelioration  of 
urgent  symptoms. 

Malignant  growths  of  the  thymus  are  rare.  General  tuberculous  in- 
vasion not  infrequently  includes  the  thymus,  while  syphilitic  gummata 
and  abscesses  from  infective  emboli  have  been  found.  Dermoid  cysts 
have  also  been  found  in  this  gland.  This  is  not  surprising  when  its  em- 
bryologic  development  from  the  second  and  third  branchial  clefts  is 
considered. 

DISORDERS  OP  THE  THYROID. 

As  far  as  known,  the  function  of  the  thyroid  gland  is  the  secretion 
of  a  colloid  material  which,  entering  the  circulation,  exerts  a  positive 
influence  over  metabolism.  The  structure  of  the  thyroid,  with  its  enor- 
mous blood  supply,  relatively  eight  times  as  abundant  as  that  of  the 
brain,  is  suggestive  of  the  great  activity  of  this  organ,  although  the 
amount  of  the  secretion  is  not  even  approximately  known.  The  exact 
role  of  this  secretion,  in  its  relationship  to  metabolism,  is  not  yet  defi- 
nitely understood,  although  some  of  the  effects  of  interference  with 
the  function  of  the  gland  are  known. 

Of  such  conditions  there  are,  1,  congenital  absence  of  the  thyroid; 

2,  atrophy  from  overgrowth  of  fibrous  tissue  or  obliteration  of  gland 
tissue   by   neoplasms,- — as    in    syphilis,   tuberculosis,    carcinomata,    etc. ; 

3,  destruction  or  removal ;  4,  interference  with  blood  supply, — as  in 
varicose  and  aneurismal  vessels ;  5,  thyroiditis ;  6,  destruction  of  gland 
tissue  following  infectious  diseases, — as  typhoid,  measles,  etc. ;  7,  true 
hypertrophy  of  glandular  parenchyma. 

The  conditions  known  as  cretinism  and  myxcedema,  with  few  ex- 
ceptions, show  absence  or  deficiency  of  thyroid  function,  while  on  the 
other  hand  hypersecretion  of  the  thyroid,  as  seen  in  class  seven,  is 
commonly  associated  with  exophthalmic  goitre. 

Ablation  of  the  thyroid  is  not  always  followed  by  myxcedema,  and 
late  observations  seem  to  show  that  in  these  cases  the  glandular  function 
is  carried  on  by  structures  known  as  accessory  and  parathyroid  glands. 
Moreover,  it  has  been  shown  that  myxcedema  may  follow  the  removal 
of  an  accessory  thyroid,  the  inference  being  that  the  main  thyroid  was. 
functionless. 

Every  symptom  of  cretinism  is  suggestive  of  suboxidation,  while  the 
judicious  administration  of  thyroid  extract  by  mouth,  or  the  transplanta- 
tion of  thyroid  gland  into  any  vascular  area  of  the  body  of  a  cretin,  is 
followed  by  certain  well-defined  symptoms, — namely,  increase  in  metabol- 
ism, elevation  of  temperature,  increased  heart  action,  muscular  tone, 
tactile  sensibility,  mental  activity,  and  improved  nutrition  of  all  tissues 
of  the  body.    Under  thyroid  administration  the  cretin  gradually  changes 


CRETINISM 


493 


toward  the  normal ;  the  normal  child  develops  hyperesthesia,  tachy- 
cardia and  headache  with  general  hyperexcitability ;  and  the  subject  of 
exophthalmic  goitre,  with  few  exceptions,  shows  exaggeration  of  all  his 

symptoms. 


CRETINISM. 

An  infant,  to  all  appearances  normal  at  birth,  with  a  negative  his- 
tory as  to  its  gestation,  parturition,  and  heredity,  may  attract  attention 
before   its   sixth  month   by   an   apparent   overdeposit  of   subcutaneous 

adipose,  with  redundant  integument, 
large  protruding  tongue,  general 
muscular  weakness,  and  hoarse,  un- 
natural cry.  These  signs  of  malde- 
velopment  mark  the  early  stage  of 
cretinism.  If  not  arrested,  these 
signs  become  more  pronounced,  in- 
volving primarily  the  tegmental, 
muscular,  osseous,  and  nervous  sys- 
tems. The  overgrowth  of  skin  be- 
comes thickened,  with  large  deposits 
of  fat,  particularly  in  the  supraclav- 
icular regions,  which,  with  hanging 
jowls  and  nether  face,  almost  obliter- 
ate the  short,  thick  neck.  The  ears 
stand  out,  while  the  thickened  alae 
nasi,  with  upturned  nostrils,  inten- 
sify the  effect  of  the  flattened  nasal 
bridge.  With  few  exceptions  the 
hair  is  harsh  and  dry,  and  the 
sparse  eyebrows  hardly  separate  the 
transverse  wrinkles  of  the  heavy 
forehead  from  the  narrow  slits  of 
the  swollen  palpebral  tissues.  The 
whole  face  seems  bloated,  which, 
with  the  thick  lips,  large  drooling 
tongue  and  expressionless  eyes,  com- 
plete the  stamp  of  imbecility.  The 
belly  is  protuberant,  often  with  umbilical  hernia.  The  extremities  are 
short,  with  block-like  hands  and  feet,  and  clumsy,  thickened,  widely- 
separated  digits. 

Muscular  development  is  retarded  so  that  walking  is  late, — frequently 
not  acquired  until  the  fourth,  fifth,  or  even  the  twelfth  year,  and  is 
of  a  waddling  and  uncertain  gait  as  though  impeded  by  excess  of  fat. 
All  muscular  movements  are  slow  and  clumsy. 

The  fontanelle  remains  open  long  after  the  usual  time.  The  growth 
of  the  long  bones  is  retarded,  the  epiphyseal  chondral  condition  being 
prolonged  into  adolescence,  so  that  the  trunk  appears  much  out  of  pro- 


Fig.  191. — J.  L.,  cretin,  2}.<,  years. 


494  DISEASES    OF    THE    GLANDS 

portion  to  the  short  extremities.  The  stature  of  a  twelve-year-old 
cretin  may  not  exceed  that  of  an  average  child  of  three  years. 

The  harsh,  dry  skin  frequently  shows  a  furfuraceous  desquamation, 
the  nails  are  brittle  and  striated,  the  teeth  are  tardy  in  eruption  and 
are  irregular  in  form  and  distribution,  with  a  tendency  to  early  decay. 
This  is  true  of  both  temporary  and  permanent  sets.  In  older  children 
the  voice  becomes  hoarse  and  inhuman. 

The  temperature  is  almost  invariably  from  one  to  two  degrees  below 
the  normal,  and  even  during  acute  infections  there  may  be  an  absence 
of  the  usual  pyrexia. 

The  nervous  system,  both  sensory  and  motor,  seems  sluggish,  with 
general  diminution  or  absence  of  the  superficial  reflexes.  Cerebral  de- 
velopment is  retarded  and  shows  all  the  stages  from  mental  dulness  to 


Fig.  192. — Cretin,  12  years  of  age. 

absolute  idiocy.  The  cretin  is  proverbially  good-natured  and  shows 
little  evidence  of  emotion  or  pain. 

With  the  exception  of  the  habitual  constipation,  the  digestive  system 
seems  normally  active.  This  is  also  true  of  the  respiratory  organs.  The 
circulatory  and  urinary  systems  show  no  primary  involvements,  although 
secondary  changes  are  not  uncommon  in  advanced  cretinism, — as 
albuminuria  and  degenerative  renal  lesions.  The  blood  changes  are  those 
of  a  secondary  anasmia,  with  nucleated  red  cells  suggestive  of  fetal 
blood.     The  heart's  action  is  weak. 

Occasionally  the  signs  of  cretinism  are  first  observed  as  a  sequel  to 
some  acute  disease.  The  degree  may  vary  from  the  picture  of  profound 
idiocy,  above  presented,  to  very  slight  abnormalities  in  physical  or 
mental  development  which  are  recognized  as  cretinoid. 

Sporadic  cretins  are  found  the  world  over  and  no  race  is  known  to  be 
exempt.  In  a  few  localities,  notably  shut-in  valleys  among  high  moun- 
tains, cretinism  is  so  prevalent  as  to  be  endemic.     From  numerous  de- 


(.Mi  HT  IN  ISM 


495 


scriptions  no  physical  difference  can  be  established  between  the  sporadic 
and  endemic  types.  An  apparent  difference  as  to  the  causation  is  seen 
in  the  more  frequent  association  of  cretinism  and  goitre  in  localities 
where  both  are  endemic.  It  is  on  record  that  women  who  have  given 
birth  to  cretins  where  the  disorder  was  endemic,  have  borne  normal 
children  in  localities  free  from  that  influence.  Again,  women  who  have 
borne  cretinic  children  have  been  fed  on  thyroid  in  subsequent  preg- 
nancies which  terminated  in  normal  children. 

Prognosis. — The  prognosis  without  treatment  is  unfavorable  as  far 
as  amelioration  of  cretinism  is  concerned,  although  the  condition  is 
rarely  the  immediate  cause  of  death.  In  fact,  during  infancy  the  cretin 
shows  a  marked  immunity  from  the  prevalent  contagious  disorders  of 
that  period.  It  has  been  noticed  that  under  thyroid  treatment  the  dis- 
appearance of  this  immunity  is  coincident  with  that  of  the  cretinoid 
condition.    A  fair  percentage  of  cretins  have  reached  middle  life. 


Fig.  193.— J.  L.,  same  as  Fig.  191,  after  two  months'  treatment  with  thyroid  extract. 


Treatment. — The  treatment  of  cretinism  consists  in  the  administra- 
tion of  animal  thyroid,  preferably  in  the  form  of  the  extract.  Few  cases 
have  failed  to  show  marked  improvement  of  symptoms  under  its  use 
judiciously  carried  out  and  many  cases  are  reported  where  approximately 
complete  recovery  has  followed  thyroid  administration.  To  this  end 
the  treatment  should  commence  early,  hence  the  importance  of  an  early 
diagnosis.  From  one-half  to  one  grain  may  be  given  once  a  day  to  an 
infant  under  two  years,  and  continued  in  gradually  increasing  dosage, 
if  tolerated,  until  there  is  a  disappearance  of  cretinoid  signs.  The  more 
advanced  the  cretinoid  condition,  the  more  prolonged  will  be  the  period 
of  continuous  medication.  Improvement  has  been  noted  within  the  first 
month  of  treatment,  but  not  infrequently  the  first  stage  of  treatment 
will  require  a  year  or  more. 

No  treatment  should  be  undertaken  without  facilities  for  constant 
observation  on  the  part  of  the  physician,  as  much  harm  and  occasional 
deaths  have  followed  the  reckless  administration  of  this  agent. 


496  DISEASES    OF    THE    GLANDS 

An  early  and  favorable  result  of  treatment  should  be  a  slight  rise 
in  temperature,  increase  in  pulse  and  respiration,  quickened  sensibility, 
increased  elimination  of  urea,  reduction  in  weight,  and  increase  in 
height,  all  evidences  of  increased  oxidation  and  improved  metabolism. 
If  the  dose  be  excessive  these  symptoms  will  be  intensified, — such  as 
pyrexia,  tachycardia,  headache,  rapid  respiration,  diarrhoea,  glycosuria, 
albuminuria  and  tremors  with  a  tendency  to  syncope ;  in  other  words,  a 
push  too  far,  a  hyperthyroidism. 

The  physician  must  not  forget  the  increased  liability  of  his  patient 
to  intercurrent  affections  while  under  treatment  and  should  be  ready  at 
any  time  to  diminish  or  withhold  the  agent  for  a  time.  Additional  pro- 
tection against  cold,  or  even  removal  to  warmer  climate  during  the 
winter  months,  is  desirable. 

Physical  improvement  is  earlier  and  more  marked  than  that  of  the 
mental  condition.  Growth  in  stature  is  oftentimes  remarkable,  and  the 
bones,  especially  those  of  the  legs,  show  a  tendency  to  curvature.  This 
must  be  guarded  against  by  restriction  of  exercise.  Cretins  rarely  reach 
the  average  mentality  for  age  under  the  best  of  care,  although  physically 
up  to  the  standard.  Much  disappointment  will  be  avoided  if  the  fact 
be  recognized  that  cretinism  is  the  result  of  a  thyroid  defect  beyond 
the  corrective  power  of  the  individual,  and  that  this  must  be  supplied 
by  the  administration  of  the  animal  thyroid  throughout  life.  This  need 
not  be  continuous,  however,  after  the  first  period  of  treatment.  The 
daily  administration  of  the  extract  for  a  month  in  the  year,  or  for  a 
week  during  each  month,  has  been  found  sufficient  in  some  cases  to 
prevent  a  recurrence  of  cretinoid  signs.  Each  case,  however,  should  be 
governed  by  the  individual  susceptibility,  and  a  small  daily  dose  through- 
out life  may  be  found  necessary  to  maintain  normal  metabolism. 

EXOPHTHALMIC    GOITRE — GRAVES 'S   DISEASE;   BASEDOW'S   DISEASE. 

That  the  condition  known  as  exophthalmic  goitre  is  due  to  increased 
functional  activity  of  the  thyroid  gland  ,is  the  belief  most  prevalent. 
The  fact  that  all  post-mortem  reports  on  exophthalmus,  with  rarely  an 
exception,  show  enlargement  of  the  thyroid,  even  when  not  observable 
during  life,  and  that  a  large  percentage  of  operated  cases  have  shown 
improvement  after  removal  of  a  portion  of  the  gland,  are  confirmatory 
of  the  above  opinion. 

Graves's  disease,  although  rare  in  infancy  and  childhood,  is  suffi- 
ciently frequent  to  warrant  its  mention.  The  symptoms  vary  somewhat 
from  those  seen  in  adult  life, — the  tachycardia  may  be  extreme;  the 
goitre  is  more  constant  than  in  adults;  the  exophthalmus  and  other 
ocular  signs  are  seldom  pronounced,  and  the  tremors  are  rarely  seen, 
choreic  manifestations  being  more  frequent.  The  youngest  child  whose 
case  has  been  reported  was  two  and  one-half  years  old.  It  has  been 
known  to  develop  in  childhood  after  acute  infections, — as  scarlet  fever 
and  influenza. 

The  symptom  complex  of  this  disorder  is  of  shorter  duration  in 


EXOPHTHALMIC    GOITRE  497 

children  and  appears  often  more  suddenly  than  in  adults.  A  ease 
is  reported  in  which  symptoms  developed  and  subsided  in  ten  days. 
The  approach  of  puberty  marks  the  greatest  frequency  of  these  symp- 
toms. Probably  this  age  furnishes  the  best  examples  of  hyperanuc 
goitres,  which  may  be  accompanied  by  tachycardia,  thus  simulating 
Graves's  disease. 

The  goitre  of  puberty  yields  in  a  few  months,  with  proper  treat- 
ment, and  may  disappear  spontaneously  after  the  establishment  of 
menstruation.  The  differentiation  between  Graves's  disease  and  hyper- 
aemic  goitre  with  rapid  heart  action  is  not  always  easy.  A  number 
of  examinations  may  be  necessary  to  determine  the  persistency  of  the 
tachycardia,  in  the  absence  of  which  the  diagnosis  of  Graves's  disease  is 
improbable.  Transient  palpitation  must  therefore  be  excluded,  as  must 
also  rapid  pulse  due  to  organic  heart  disease. 

Heredity  undoubtedly  plays  an  important  role  in  the  etiology  of 
Graves's  disease.  In  fact,  the  neuropathic  is  given  precedence  over 
the  glandular  disturbance  by  many  able  observers  who  cite  neurotic 
family  histories — as  epilepsy,  chorea,  hysteria,  and  alcoholism — in  a 
majority  of  their  patients.  Some  remarkable  instances  of  this  disease, 
as  a  family  affection,  are  reported,  where  all  five  children  of  the  same 
mother  showed  some  of  the  cardinal  symptoms  of  Graves's  disease. 
Other  reports  give  histories  of  exophthalmic  goitre  in  four  successive 
generations. 

Treatment. — In  severe  cases,  the  child  should  be  confined  to  bed,  or 
at  least  kept  in  the  horizontal  position  and  restricted  to  a  light,  nutri- 
tious, and  nonstimulating  diet.  Elimination  must  be  promoted  by  laxa- 
tives, diuretics,  and  gentle  massage,  if  well  borne.  Cardiac  sedatives, 
especially  tincture  of  strophanthus,  beginning  with  minimum  doses  with 
gradual  daily  increase,  carefully  watched,  may  be  needed.  In  extreme 
cases  ice-bags  over  the  pericardium,  if  well  borne,  are  efficacious.  For 
the  goitre,  aside  from  surgical  interference,  which  has  some  advocates, 
galvanism  has  been  found  effective  in  reducing  the  size  of  the  tumor 
with  amelioration  of  all  the  symptoms.  The  galvanic  current  of  two 
or  three  milliamperes  may  be  used  two  or  three  times  a  week  for  from 
one  to  three  minutes.  This  treatment  must  be  continued  for  weeks  and 
even  months.  The  daily  application  over  the  thyroid  gland  of  iodine 
ointment  or  that  of  the  iodide  of  mercury,  with  gentle  massage,  has 
proved  beneficial  in  some  cases.  The  internal  administration  of  eligible 
preparations  of  iron,  as  syrup  of  the  iodide,  in  small  doses,  are  indicated 
for  the  anaemia.  The  value  of  suprarenal  and  thymus  preparations  is 
still  sub  judice.  The  administration  of  thyroid  extract  is  contraindicated. 
The  resemblances  between  the  symptoms  of  exophthalmic  goitre  and 
fright  are  so  striking  as  to  suggest  a  line  of  treatment.  This  should 
include  absolute  freedom  from  anxiety,  and  measures  to  secure  entire 
mental  and  physical  repose. 

The  value  of  rodagen  from  the  thyroidectomized  goat  is  now  on  trial 
in  this  disease,  and  has  found  a  number  of  enthusiastic  advocates,  as  has 

32 


498  DISEASES   OF   THE  BLOOD 

also  the  serum  from  thyroidectoniized  animals,  which  is  administered  in 
tablet  form. 

ANMMIA. 

Anaemia  is  a  condition  in  which  there  is  a  deficiency  of  haemoglobin 
or  of  one  or  more  of  the  corpuscular  elements  of  the  blood.  The  present 
knowledge  of  anaemias  does  not  permit  a  definite  scientific  classification. 
Those  classifications  most  in  vogue  depend  partly  upon  preceding  or 
associated  conditions,  and  partly  upon  the  known  peculiar  changes  in 
the  blood  itself.  They  have  been  called  primary,  idiopathic,  or  essential, 
in  the  absence  of  any  known  cause  (pernicious  anaemia,  chlorosis,  and 
leukaemia),  and  secondary  or  symptomatic  anaemia  when  preceded  or 
accompanied  by  conditions  upon  which  the  blood  changes  clearly  or 
presumably  depend.  The  growing  belief  is  that  all  anaemias  are  sec- 
ondary or  symptomatic, — i.e.,  that  the  blood  conditions  are  symptomatic 
of  some  preexisting  or  accompanying  disturbance  in  the  metabolic  pro- 
cess upon  which  the  integrity  of  the  blood  depends. 

Among  the  known  causes  of  anaemia  in  childhood  are  hemorrhages 
and  toxines.  Hemorrhages  may  result  from  traumatisms  or  occur  in  the 
course  of  disease.  Intoxications  may  follow  the  ingestion  of  drugs,  as 
chlorate  of  potash,  mercury,  etc. ;  any  of  the  acute  infectious  fevers, — 
as  malaria,  diphtheria,  etc. ;  malignant  neoplasms, — as  sarcoma  or  car- 
cinoma ;  nutritional  disorders, — as  rickets  or  scorbutus ;  enteric  disturb- 
ances,— as  enteritis  or  intestinal  parasites;  and  organic  lesions, — as- 
nephritis  and  disease  of  the  central  nervous  system.  In  general,  any 
condition,  physical  or  environmental,  that  interferes  with  normal  nutri- 
tion, may  be  counted  a  factor  in  anaemia.  That  the  infant  or  child 
is  peculiarly  susceptible  or  prone  to  blood  deterioration  is  well  known. 
Indeed,  the  entire  period  of  development  is  a  struggle  for  blood  equi- 
librium, and  anaemia  in  varying  degree  is  the  rule  rather  than  the  ex- 
ception during  this  precarious  period.  An  explanation  for  this  is  seen 
in  the  peculiarities  of  infant  blood.  The  fact  is  that  the  enormous 
demands  for  daily  tissue  growth,  work  the  blood-making  organs  to 
their  full  capacity.  Moreover,  the  child  must  run  the  gamut  of  infectious 
diseases  before  immunity  is  secured. 

It  is  seen  that  the  chief  characteristic  of  infant  blood  is  the  low 
degree  of  haemoglobin  and  specific  gravity.  Moreover,  the  red  cells  have 
less  stability,  exhibit  a  greater  variety  of  forms,  present  staining  pecu- 
liarities (polychromatophilia),  part  with  their  haemoglobin  more  readily, 
and  on  slight  provocation  show  nucleated  forms  (normoblasts).  That 
is,  the  tendency  to  reversion  toward  fetal  blood  conditions,  of  such  grave 
pathologic  significance  in  the  adult,  is  characteristic  throughout  the 
period  of  childhood.  Slight  loss  of  blood,  transient  infection,  and  even 
temporary  digestive  disturbances,  produce  a  marked  effect  upon  the 
already  low  color  index,  so  that  the  condition  of  hydraemia  is  common, 
and  although  children  make  blood  rapidly,  it  is  with  great  difficulty. 
TVhile  the  excess  of  red  marrow  shows  great  activity  in  the  blood-making 
processes,  the  child  is  unable  to  keep  up  with  the  enormous  demands 


ANvEMIA  499 

for  growth  at  this  time,  even  with  the  accessory  work  in  the  spleen  and 
other  adenoid  tissues,  and,  possibly,  the  liver.  In  other  words,  the  blood- 
makers  have  no  reserved  store  of  material  for  emergencies,  as  seen  in  the 
yellow  bone  marrow  of  the  adult.  In  this  difficulty  of  supplying  the 
ever-increasing  demand  for  normal  blood  elements,  interrupted  as  it  is 
by  the  recurrent  causes  of  antenna,  is  seen  the  ever-present  handicap  of 
infancy. 

In  infantile  anosmias  the  presence  of  a  large  number  of  white  cells 
is  less  significant  than  when  seen  in  the  adult,  as  hyperleucocytosis 
is  practically  normal.  The  large  proportion  of  lymphocytes  is  but 
one  of  the  expressions  of  the  intense  glandular  activity  of  this  period, 
while  splenic  enlargement  is  a  common  accompaniment  of  childhood 
anaemias. 

Symptoms. — If  the  hydraemia  be  extreme,  the  deficiency  of  haemo- 
globin shows  in  the  pallor  of  the  skin,  but  is  particularly  marked  in  the 
mucosa  of  the  mouth  and  the  conjunctivae.  The  selerotics  are  pearly, 
the  ears  have  a  waxy  appearance,  the  muscular  system  is  atonic,  and 
the  child  is  listless  and  fatigues  easily.  He  is  often  peevish  and  fret- 
ful, subject  to  vague  pains  in  limbs  and  viscera.  Headache  is  common. 
The  pulse  is  weak,  rapid,  and  occasionally  irregular.  A  hoemic  mur- 
mur may  be  heard  over  the  heart  (particularly  over  the  pulmonary 
area),  although  not  so  commonly  in  very  young  infants.  A  venous 
hum  may  be  heard  over  the  great  vessels  of  the  neck.  Respirations 
are  shallow,  with  dyspnoea  on  slight  exertion,  and  occasionally  moist 
rales  are  heard.  Vertigo  with  tinnitus  aurium  and  syncope  occur  in 
extreme  cases.  Digestive  disorders,  with  capricious  appetite  or  disin- 
clination for  food,  are  common.  Catarrhs  of  the  nasopharyngeal  mucosa 
are  frequent,  with  tonsillar  and  adenoid  engorgement  and  recurrent 
epistaxis.  So,  also,  vesical  irritability  or  sphincter  atony  with  inconti- 
nence may  be  a  result.  Vulvovaginal  catarrhs  are  occasionally  seen  in 
girls.  Cold  hands  and  feet  attest  the  diminished  oxidation,  while  ambly- 
opia and  symptoms  of  eyestrain,  hallucinations,  broken  sleep,  and  bad 
dreams,  with  mental  morbidity,  are  among  the  train  of  symptoms. 

Too  frequently  anaemia  is  overlooked  as  the  cause  of  innumerable 
affections,  to  many  of  which  it  may  be  justly  attributed  also  as  an  effect. 

Diagnosis. — The  diagnosis  should  not  wait  for  the  full  development  of 
the  foregoing  too  common  picture  of  neglected  anaemia.  The  lips  may 
be  bright  red  and  the  cheeks,  especially  under  excitement,  show  height- 
ened color,  in  spite  of  a  very  appreciable  fall  in  haemoglobin.  Any 
signs  of  irritability,  headache,  capricious  appetite,  or  tendency  to  "cold 
catching,"  should  lead  to  a  suspicion  of  anaemia,  which  may  be  con- 
firmed by  examination  of  the  blood.  Haemanalysis  should  be  kept  up 
at  intervals  after  all  of  the  infectious  fevers  until  the  blood  becomes 
again  normal.  The  fact  cannot  be  unduly  emphasized  that  in  the 
secondary  anaemias  lies  the  greatest  danger  from  all  the  infections  of 
childhood,  and  that  a  physician's  duty  is  not  completed  with  the  ter- 
mination of  the  acute  attack. 


500  DISEASES    OF    THE    BLOOD 

Prognosis. — The  prognosis  of  the  morbid  results  of  a  persistent 
anaemia  in  childhood  is  obvious.  It  furnishes  a  constant  predisposition 
to  a  multitude  of  infections  and  the  many  disturbances  of  metabolism. 
The  name  of  some  intercurrent  disease  usually  appears  upon  the  death 
certificate. 

Treatment. — The  treatment  of  anaemia  consists  first  in  the  removal 
or  mitigation  of  the  cause.  The  primary  cause  may  have  disappeared 
long  since.  It  is  then  necessary  to  break  up  the  vicious  circle  of  sec- 
ondary causes  and  their  effects,  as  impaired  muscular  tonicity  with  its 
weakened  cardio-vascular  conditions ;  impoverished  secretions  with  their 
train  of  digestive  disturbances;  neurasthenia  with  its  exhausting  in- 
somnia ;  mucous  catarrhs  with  their  constant  production  of  intoxications, 
and  the  general  impairment  of  nutrition  from  all  these  distressing  causes 
combined. 

The  anaemia  itself  must  be  treated  by  efforts  to  increase  the  number 
of  erythrocytes,  and  particularly  the  percentage  of  haemoglobin.  If 
accomplished,  this  will,  by  the  improved  oxidation,  greatly  relieve  the 
other  morbid  conditions.  Of  prime  importance  are  nutritious  foods, 
adapted  to  the  condition  of  the  digestive  organs,  plenty  of  air  with  high 
percentage  of  oxygen,  with  exercise  to  promote  deep  respiration  but  not 
to  the  degree  of  excessive  fatigue,  bathing  with  friction  and  massage, 
the  maximum  amount  of  sleep  with  perfect  ventilation,  and  relief  from 
school  (for  older  children),  or  fatiguing,  worrying  tasks.  Iron  and 
arsenic  in  suitable  forms  are  valuable  adjuncts  to  a  careful  hygienic 
regimen. 

CHLOROSIS. 

Although  not  a  disorder  of  childhood,  chlorosis  is  of  interest  in  the 
study  of  the  developing  period.  Very  few  cases  have  been  reported  in 
boys. 

The  cause  is  not  understood,  all  the  various  etiologic  theories  pre- 
viously advanced  having  been  proved  untenable.  The  period  of  its 
occurrence  and  the  occasions  under  which  it  is  known  to  recur,  point 
to  ovulation  or  some  disturbance  of  the  menstrual  function  as  etiologi- 
cally  significant.  The  nature  of  that  disturbance  and  the  predisposing 
conditions  which  have  long  been  regarded  as  intimately  related  with  the 
development  of  chlorosis  are  at  present  a  mystery.  Shock,  fatigue,  ex- 
posure to  cold,  mental  emotions — as  homesickness,  grief,  and  many  other 
conditions  which  have  done  duty  in  its  etiologic  category — can  only  be 
considered  as  exciting  causes. 

The  blood  findings  are  unique.  There  is  lowered  specific  gravity, 
a  somewhat  diminished  number  of  erythrocytes,  disproportionately 
reduced  haemoglobin,  with  poikilocytosis  and  normoblasts  in  severe 
cases.  The  leucocytes  show  little  change.  The  specific  gravity  of  the 
plasma  is  higher  than  normal  and  the  fluid  shows  increased  tendency 
to  clot. 

The  symptoms  of  the  disease  are  due  primarily  to  circulatory  dis- 


PERNICIOUS    AJSLEMIA  501 

turbances.  The  muscular  structures  of  the  heart  and  vessels  show  want 
of  oxygen,  and  this  is  shared  by  all  muscular  t  issues  of  the  body.  General 
muscular  atony,  with  cardiac  dilatation,  apical  and  basal  murmurs, 
venous  hum,  palpitation,  dyspnoea,  vertigo,  syncope,  indigestion,  flatu- 
lence, morbid  appetite,  gastroptosis,  constipation,  pale  mucosae,  pearly 
sclerotics,  and  in  about  sixty  per  cent,  of  cases  a  greenish-yellow  hue  of 
the  skin,  are  some  of  the  conditions  seen  in  this  disease. 

There  is  a  predisposition  to  venous  thrombosis  and  to  the  develop- 
ment of  gastric  ulcer. 

Diagnosis  based  upon  the  clinical  picture  and  the  blood  findings  is 
not  difficult.  Pulmonary  tuberculosis  shows  greater  emaciation,  char- 
acteristic pulmonary  symptoms,  and  bacilli  in  the  sputum. 

The  duration  of  chlorosis  may  be  from  a  few  months  to  a  year,  with 
the  possibility  of  recurrence  of  symptoms. 

It  is  rarely  fatal  except  from  such  complications  as  gastric  ulcer  or 
tuberculosis. 

In  the  treatment  of  chlorosis  iron  has  proved  a  specific  in  the  resto- 
ration of  hemoglobin.  The  indications  for  oxygen  call  for  a  plenti- 
ful supply  of  fresh  air.  Constipation  must  be  relieved, — best  by  the 
free  use  of  fruits,  massage,  and  a  regular  habit  in  efforts  at  defecation. 
If  these  means  are  at  first  insufficient,  cascara,  mix  vomica,  or  rhubarb 
may  be  used  temporarily.  Dietary  errors — as  excess  of  candy,  cakes,  or 
pickles — must  be  corrected.  Mental  influences  have  much  to  do  in 
promoting  assimilation,  so  that  frequently  a  change  of  environment  will 
hasten  recovery. 

PERNICIOUS   ANEMIA. 

The  assumption  that  pernicious  anaemia  is  rare  in  infancy  is  based 
upon  the  number  of  reported  cases.  This  is  an  unfair  conclusion  when 
the  infrequency  of  blood  examination  in  the  disorders  of  this  age  is  con- 
sidered. The  readiness  with  which  anaemia  develops  in  infancy  and 
early  childhood  is  well  known.  In  children,  as  in  adults,  digestive  dis- 
turbances have  naturally  been  accredited  with  the  symptoms  of  the 
progressive  debility,  and  even  the  anaemia  itself. 

The  list  of  causes,  predisposing  and  exciting,  which  has  been  given 
for  pernicious  anaemia,  would  include  almost  every  condition  and  in- 
fection that  is  known  to  lower  vitality  or  cause  general  debility.  The 
fact  that  intestinal  parasites  can  produce  all  the  clinical  symptoms,  in- 
cluding a  picture  of  the  blood  findings,  which  invariably  disappear  upon 
the  removal  of  the  cause,  increases  the  etiologic  confusion  of  this  dis- 
ease. The  belief  in  the  infectious  origin  of  pernicious  anaemia  is  widely 
prevalent,  although  as  yet  no  specific  micro-organism  or  group  has  been 
discovered. 

The  chief  characteristic  is  the  extensive  haemolysis  to  which  all  the 
blood  findings  point.  The  volume  of  blood  is  said  to  be  diminished, 
specific  gravity  is  lessened,  the  erythrocytes  are  reduced  in  number  (not 
infrequently  below  1,000,000,  sometimes  below  200,000  per  C.c.),  and 


502  DISEASES    OF    THE    BLOOD 

the  haemoglobin  is  diminished,  although  its  percentage  is  relatively  high 
(high  color  index). 

There  is  marked  poikilocytosis  with  large  numbers  of  nucleated  red 
corpuscles,  in  which  the  megaloblasts  far  outnumber  the  normoblasts, 
also  a  prevalence  of  macrocytes  but  paucity  of  microcytes.  The  presence 
in  the  blood  serum  of  debris  and  other  evidences  of  cell  destruction,  to- 
gether with  staining  anomalies  (polychromatophilia),  is  characteristic. 
The  rouleaux  agglutination  of  the  red  cells  is  lost.  In  the  early  stage, 
the  drawn  drop  of  blood  is  a  bright  red,  but  later  looks  thin  and  pale 
(hydraemia).  Iron  from  the  disintegrating  red  corpuscles  is  found  in 
all  the  viscera,  particularly  the  liver,  while  cell  nuclei  and  free  haemo- 
globin appear  in  the  blood  stream.  The  picture  is  one  of  blood  destruc- 
tion rather  than  that  of  disease  of  the  blood-making  organs.  There  is 
little  or  no  increase,  but  frequently  diminution  in  the  number  of  white 
cells,  of  which  a  large  proportion  are  lymphocytes.  Myelocytes  are  rare 
or  absent. 

The  symptoms  are  those  of  a  general  anaemia,  with  little  or  no 
emaciation.  The  rotundity  of  the  figure  persists  throughout  in  many 
instances,  although  muscular  atony  and  general  flabbiness  of  the  tissues 
are  always  present.  The  color  of  the  skin  is  usually  described  as  lemon 
yellow  rather  than  waxy,  pallid,  or  pigmented.  Petechias,  ecchymoses, 
and  hemorrhages,  especially  epistaxis,  are  common.  Disturbed  vision, 
even  blindness,  may  result  from  retinal  hemorrhage.  Stomatitis  and 
glossitis  are  frequent  accompaniments,  and  gastro-enteric  disturbances 
are  usual  during  the  progress  of  the  disease. 

The  urine  is  pale,  of  low  specific  gravity  (1006),  neutral  or  alkaline 
in  reaction,  and  frequently  contains  albumin  and  a  few  hyaline  casts,  or 
it  may  be  dark  with  bile  pigments  or  contain  uric  acid  and  an  excess  of 
urates. 

During  the  course  of  the  disease  there  is  occasional  pyrexia  with 
irregular  fluctuations,  toxic  in  character.  The  pulse  is  usually  rapid, 
soft,  compressible,  and  frequently  irregular.  The  heart  is  enlarged, 
and  systolic  murmurs  are  heard  both  at  the  apex  and  base.  OEdema 
of  dependent  parts  is  a  common  symptom  and  occasionally  there  are 
accumulations  of  fluid  in  serous  cavities.  Fatty  degeneration  is  common 
in  the  heart-muscle,  blood-vessels,  and  many  other  organs,  late  in  the 
disease. 

Parassthesia,  ataxic  symptoms,  and  muscular  incooordination  with 
rapid  muscle  atrophy,  may  occur  from  hemorrhages  or  secondary  lesions 
in  the  spinal  cord. 

The  progressive  increase  in  the  languor  and  debility  is  usually  inter- 
rupted by  periods  of  apparent  improvement  of  all  the  symptoms,  so  that 
a  certain  degree  of  periodicity  of  exacerbations  is  the  rule  in  the  down- 
ward progress  of  this  disease. 

The  duration  is  essentially  chronic  and  may  continue  with  remissions 
from  a  few  months  to  three  or  four  years,  although  children  rarely  sur- 
vive a  long  period. 


LEIK.K.MIA  503 

The  symptoms  of  pernicious  anaemia,  although  suggestive,  are  never 
conclusive.  The  diagnosis  depends  upon  the  careful,  repeated  examina- 
tion of  the  blood,  and  the  absence  of  any  known  cause. 

DIAGNOSTIC    POINTS    OF    BLOOD    IN    PERNICIOUS    AX. K.MIA. 

1.  Low  specific  gravity.  5.  Polychromatophilia. 

2.  Extreme  reduction  in  red  cells.  6.  Haemoglobin  reduced,  but 
;;.  Erythroblasta  numerous.  7.  Color  index  high. 

4.  Mcgaloblasts     many;     normoblasts        8.  Leucocytes    normal    or    diminished, 
few. 

Prognosis. — Recovery  from  pernicious  anaemia  is  claimed  in  a  few 
cases,  but  this  must  be  questioned. 

Treatment. — Aside  from  the  general  treatment  for  anaemia  the  agent 
most  highly  regarded  in  pernicious  anaemia  is  arsenic,  which  should  be 
administered  to  the  full  degree  of  toleration.  The  possibility  of  a  gastro- 
intestinal infection  as  a  cause  for  pernicious  anaemia  has  led  to  a  thor- 
ough antiseptic  treatment  of  the  digestive  tract,  with  encouraging  re- 
sults. Lavage  and  enteroclysis  are  indicated.  Antiseptic  agents — as 
mercuric  chloride,  thymol,  or  betanaphthol — are  administered  cautiously, 
care  being  taken  to  conserve  digestion. 

Muscular  exertion  or  any  expenditure  of  energy  must  be  reduced  to 
the  minimal  point  and  systematic  daily  massage  substituted.  Inhalation 
of  oxygen  is  theoretically  indicated.  In  extreme  cases  this  may  be  re- 
peated four  or  five  minutes  every  hour  during  the  waking  period.  Serum 
therapy  has  its  advocates  and  the  antistreptococcus  serum  has  been  used 
with  success.  The  cacodylate  of  sodium  is  also  highly  recommended  by 
recent  writers  on  the  subject. 

LEUKAEMIA. 

Leukaemia  is  a  term  applied  to  a  condition  of  the  blood  in  which  not 
only  the  numerical  ratio  between  the  red  and  white  cells  is  changed  but 
both  show  marked  morphological  changes.  This  ratio  between  leucocytes 
and  erythrocytes  varies  from  1  to  100  up  to  1  to  15.  Cases  have  been 
reported  in  which  the  leucocytes  equalled  one-half  the  number  of  erythro- 
cytes. This  disturbed  ratio  is  the  result  of  the  enormous  leucocytosis 
rather  than  a  poverty  of  erythrocytes,  although  the  red  cells  show  a 
diminution, — 2,000,000  frequently,  and  even  as  low  as  800,000  per  C.mm. 
having  been  recorded. 

In  the  white  cells  the  normal  polymorphonuclear  neutrophiles  are 
replaced  by  an  enormous  overgrowth  of  lymphocytes  and  myelocytes. 
Nucleated  red  cells,  also  microcytes  and  macrocytes,  are  present.  Poikilo- 
cytosis  and  karyokinesis  are  to  be  seen.  The  specific  gravity  and  haemo- 
globin correspond  with  the  decrease  in  erythrocytes. 

Leukaemia  is  properly  classed  among  the  rare  diseases.  The  com- 
paratively greater  infrequency  in  infancy  and  childhood  may  possibly 
diminish  upon  the  application  of  the  same  diagnostic  methods  that  are 
used  among  adults.     Much  confusion  in  classification  has  resulted  from 


504  DISEASES    OF    THE    BLOOD 

the  failure  to  appreciate  the  peculiarities  of  normal  metabolism  during 
the  developing  period,  and  that  haematogenetic  processes  in  infancy  ex- 
hibit normal  peculiarities  that  would  be  regarded  pathological  in  adult 
life,  chief  among  which  is  the  ready  reversion  to  fetal  types.  Lympho- 
cytosis is  the  blood  condition  of  infancy;  hyperleucocytosis  is  normal, 
and  nucleated  red  cells  appear  without  great  pathological  significance. 

Etiology. — The  etiology  is  unknown.  Of  many  theories  the  two  re- 
ceiving the  most  attention  to-day  are  the  infectious,  from  bacteria  or 
their  toxins,  and  the  neoplastic.  No  micro-organism  constant  in  all  cases 
of  leukaemia  has  thus  far  been  isolated  from  the  blood  or  other  tissue, 
although  a  striking  analogy  is  seen  between  some  of  the  acute  cases  and 
sepsis,  especially  in  the  sudden  onset,  rapid  course,  hypertrophy  of 
lymph  glands  and  spleen,  great  anaemia,  and  tendency  to  hemorrhage. 

The  neoplastic  theory  is  based  upon  the  fact  that  normal  lymphatic 
tissue  shows  a  marked  tendency  to  hyperplasia  and  is  replaced  by 
lymphadenoid  tissue  of  atypical  character.  This  abnormal  tissue  shows 
a  tendency  to  invade  neighboring  structures,  even  the  walls  of  blood- 
vessels, with  destruction  of  their  endothelium.  These  and  other  metas- 
tases in  the  chronic  form  of  leukaemia,  with  the  clinical  picture  of 
cachexia,  are  suggestive  of  malignant  growths. 

The  disease  may  occur  at  any  age,  a  few  congenital  cases  being  on 
record.  Among  the  predisposing  causes,  heredity  has  been  mentioned 
with  some  show  of  evidence.  It  has  developed  in  the  syphilitic,  rhachitic, 
tubercular,  and  lymphatic,  and  after  traumatisms,  attacks  of  malaria, 
influenza,  and  gastro-enteritis,  with  a  possibility  of  etiologic  relationship. 

Usually  the  disease  develops  insidiously.  The  duration  may  be  from 
one  to  twenty-five  weeks,  but  as  there  is  no  means  of  noting  the  exact 
inception,  the  probability  is  that  the  morbid  process  is  of  much  longer 
duration  and  that  frequently  the  first  pronounced  symptoms  are  really 
the  terminal.  The  division,  however,  into  acute  and  chronic  is  con- 
venient and  seems  warrantable  from  the  character  and  duration  of 
the  symptoms  in  different  cases. 

The  first  evidence  of  this  disorder  may  be  a  hemorrhage,  marked  or 
slight,  from  the  nose,  mouth,  stomach,  or  bowels,  with  a  history  of 
recent  indisposition.  There  may  be  a  rise  of  temperature  (101°-103° 
F.,  38.5°-39.5°  C.)  preceded  by  a  chill  or  vomiting.  Diarrhoea  may 
be  present,  with  anorexia  and  coated  tongue.  The  child  is  pale  and 
anaemic  and  there  may  be  hemorrhagic  spots  in  the  mouth.  Petechiae 
or  ecchymoses  may  appear  over  the  trunk  and  limbs.  There  may  be 
headache  and  disturbance  of  vision  from  retinal  hemorrhages.  The 
spleen  is  enlarged  and  sometimes  tender,  and  the  liver  is  somewhat 
larger  than  normal.  There  is  no  ascites.  Tenderness  on  pressure  may 
be  found  along  the  tibiae.  The  glands  in  the  neck  axillae,  and  groins  are 
palpable.  Haemic  murmurs  are  heard  over  the  base  of  the  heart  and 
the  great  vessels  of  the  neck.  The  lungs  frequently  are  negative.  There 
may  be  a  slight  amount  of  albumin  in  the  urine  and  also  some  blood 
cells.    Uric  acid  is  increased  in  amount. 


LEUKEMIA  505 

The  course  is  acute,  with  rapid  emaciation,  prostration,  and  intensi- 
fication of  all  the  symptoms,  death  intervening  from  pulmonary  oedema 
or  from  hemorrhage.  Many  cases  run  a  more  chronic  course  and  death 
results  from  asthenia.  Throughout  the  disease,  the  blood  count  shows 
an  increasing  lymphocytosis,  a  sudden  fall  in  the  white  corpuscles  pre- 
ceding, by  a  few  days,  a  fatal  termination.  Accompanying  this  decrease 
there  is  a  marked  reduction  in  the  size  of  the  spleen,  with  partial 
subsidence  of  the  lymph  glands. 

In  the  chronic  type  the  fever  is  less  marked  or  absent,  and  emaciation 
and  loss  of  strength  gradual.  The  child  may  walk  about  with  little 
discomfort,  excepting  for  easily  induced  dyspnoea  and  fatigue.  The 
spleen  may  become  enormously  large  and  hard  and,  curiously,  show  tem- 
porary variations  in  size  and  consistency.  The  glands,  especially  in  the 
neck,  become  aggregated  in  masses  as  large  as  a  hen's  egg,  without 
signs  of  suppuration.  Hemorrhages  may  be  frequent  and  alarming, 
after  which  the  blood  shows  enormous  increase  in  lymphocytes.  The 
sternum  and  long  bones  may  show  tenderness,  and  even  tumefaction 
or  nodules ;  the  pulse  is  weak  and  rapid ;  the  heart  may  be  dilated ; 
the  skin  is  pallid  and  waxy.  In  advanced  stages,  oedema  due  to 
haemic,  cardiovascular,  and  obstructive  causes  is  rarely  absent.  Death 
from  asthenia  may  be  forestalled  by  hemorrhage  or  some  intercurrent 
affection. 

The  present  trend  of  opinion  is  that  the  disease  is  primarily  myelo- 
genetic  in  all  cases. 

Two  widely  distinct  types  of  this  disease — namely,  myelocytic  and 
lymphocytic — are  recognized.  In  the  former  the  splenic  enlargement 
is  an  early  and  prominent  symptom,  and  in  the  leucocytosis  the  myelo- 
cytes greatly  predominate,  frequently  reaching  sixty  per  cent,  of  the 
total  whites.  The  polymorphonuclears  and  eosinophiles  are  much  in- 
creased in  absolute  numbers,  although  not  relatively.  The  same  is  true 
of  both  large  and  small  lymphocytes.  No  other  known  condition  presents 
such  a  variety  of  associated  cellular  elements.  It  is  this  richness  in 
varied  cell  forms  that  constitutes  the  blood  picture  of  the  disease,  al- 
though the  preponderance  of  myelocytes  is  pathognomonic  of  the  myelo- 
cytic form. 

It  is  in  the  second  or  lymphocytic  type  that  the  interest  for  the 
pediatric  student  mostly  lies,  for  this  is  the  form  of  leukaemia  most 
frequently  seen  in  infancy  and  childhood.  It  should  be  recalled  in  this 
connection  that  at  this  age  the  blood  shows  a  normal  tendency  to  lympho- 
cytosis and  there  is  great  activity  of  the  lymphatic  glands.  Sometimes 
there  occur  mixed  forms  in  which  the  myelocytic  blood  changes  are  ac- 
companied by  lymphadenitis,  or  the  lymphocytic  form  may  show  early 
and  marked  enlargement  of  the  spleen. 

Clinically,  the  lymphocytic  type  is  characterized  by  extensive  en- 
largement of  the  lymph  nodes  with  only  moderate  splenic  hypertrophy. 
The  blood  picture  furnishes  the  differentiation  in  an  overwhelming 
preponderance  of  lymphocytes  over  all  other  forms, — in  fact,  the  per- 


506  DISEASES    OF    THE    BLOOD 

centage  is  rarely  below  eighty  and  not  infrequently  reaches  ninety-nine. 
The  myelocytes  are  absent  and  eosinophiles  and  neutrophiles  are  rarely 
seen.  The  nucleated  red  corpuscles  are  fewer  than  in  the  myelocytic 
type. 

Pathologic  changes  occur  in  all  tissues  and  organs  of  the  body.  Those 
which  are  most  characteristic  and  most  constant  involve  the  haematopoi- 
etic  organs,  the  spleen,  lymph-nodes  and  bone-marrow.  The  changes 
found  post-mortem  in  the  spleen  are  those  of  true  hypertrophy,  with 
increase  of  all  its  histologic  elements.  The  capsule  is  thickened  and 
has  cicatrices  from  previous  hemorrhages  and  infarcts.  Sections  of 
the  lymph  nodes,  whether  superficial  or  deep-seated,  give  evidence  of 
marked  hypertrophy.  There  is  infiltration  of  all  parts  with  lympho- 
cytes, which  crowd  the  follicles  and  invade  the  vessel  walls  with  resultant 
hemorrhages. 

The  changes  in  the  bone-marrow,  always  present,  are  sometimes  so 
extensive  as  to  show  macroscopically  the  appearance  of  pus.  This  re- 
places the  normal  red  marrow  of  infancy  and  encroaches  to  such 
an  extent  that  actual  erosion  of  the  surrounding  shaft  results.  These 
changes  are  largely  due  to  an  overgrowth  of  lymph-nodes  normally 
present  in  the  medullary  substance.  Here,  as  elsewhere,  the  lympho- 
cytes prevail,  crowding,  eroding,  and  infiltrating  the  vessel  walls,  with 
changes  and  hemorrhages  similar  to  those  found  in  other  parts  of  the 
body. 

Diagnosis. — The  diagnosis  of  leukaemia  rests  entirely  upon  the  blood 
findings  during  life  and  upon  the  changes  in  the  bone  marrow  at  autopsy. 
After  any  severe,  prolonged  disturbance  of  nutrition,  as  from  gastro- 
enteritis, rickets,  or  tuberculosis,  a  severe  grade  of  anaemia  with  leuco- 
cytosis,  nucleated  red  cells  and  even  myelocytes,  associated  with  enlarge- 
ment of  the  spleen  and  lymph  nodes,  may  result,  owing  to  the  ease  with 
which  the  blood  in  early  life  reverts  to  the  fetal  type.  It  may  be  difficult 
or  even  impossible  to  differentiate  this  from  an  early  stage  of  true 
leukaemia.  The  evident  cause,  improvement  under  treatment,  and  ulti- 
mate recovery,  would  finally  locate  the  case  among  secondary  anaemias. 
The  tendency  to-day  is  to  do  away  with  the  term  "pseudo"  as  in 
' '  pseudoleukaemia  of  infancy,  anaemia  splenica  pseudoleukaemia  of  von 
Jaksch, ' '  in  anticipation  of  a  better  knowledge  as  to  the  causes  of  many 
forms  of  anaemia. 

Prognosis. — At  present,  the  prognosis  of  leukaemia  is  extremely  grave. 

Treatment. — Until  the  etiology  is  known,  the  treatment  must  be 
palliative  and  symptomatic.  The  administration  of  arsenic  induces  a 
return  of  the  blood  constituents  to  their  normal  proportion,  yet  children 
have  died  after  the  disappearance  of  the  hyperleucocytosis  during  the 
administration  of  this  drug.  Iron  and  oxygen  are  indicated  and  their 
judicious  use  has  seemed,  in  a  few  cases,  to  arrest,  at  least  temporarily, 
the  progress  of  the  disease.  The  heart  must  be  sustained  by  digitalis  or 
strychnia,  while  albumin,  of  which  there  is  an  enormous  drain,  must  be 
supplied  in  a  form  suitable  for  easy  assimilation. 


I  s 

^ 

^"^***<«  n 

*■• 

r  | 

mbKSS 

^1 

^  ~ 


HAEMOPHILIA  507 

The  hemorrhages  must  be  met  with  styptics — as  ergot,  calcium 
chloride,  or  adrenalin,  internally  or  locally — as  even  a  trifling  loss  of 
blood  is  of  great  importance  in  the  existing  anemia.  This  is  especially 
true  in  infancy. 

HAEMOPHILIA. 

Haemophilia  is  a  disorder  characterized  by  a  tendency  to  uncon- 
trollable hemorrhage  from  the  vessels  into  the  subcutaneous  tissue,  joint 
cavities,  mucous  surfaces,  and  the  skin.  The  hemorrhages  are  due  to 
capillary  oozing,  and  follow  wounds  or  abrasions,  however  slight,  and 
may  occur  spontaneously. 

The  etiology  is  unknown,  except  as  to  its  heredity,  being  transmitted, 
with  rare  exceptions,  through  the  mother,  who  may  herself  have  shown 
no  hemophilic  symptoms.  It  occurs  eleven  times  as  frecpiently  in  males 
as  in  females,  yet  the  male  rarely  transmits  the  disorder,  except  through 
a  daughter.  It  is  seen  at  all  ages, — rarely  in  advanced  life.  This  latter 
fact  is  largely  due  to  the  high  mortality  of  hemophilia  and  partly  to  the 
alleged  outgrowing  of  the  diathesis. 

No  blood  or  vascular  condition,  peculiar  to  this  class,  has  yet  been 
demonstrated. 

The  site  of  hemorrhage  is  most  frequently  the  nasal  mucous  mem- 
brane ;  next  in  order  of  frequency  are  the  mouth,  urethra  and  lungs. 
All  male  children  of  the  same  mother  may  not  be  bleeders,  the  first-born 
being  the  most  likely  to  be  exempt.  The  discovery  of  the  diathesis,  un- 
less suspected  from  the  heredity,  is  usually  made  from  some  trauma- 
tism, such  as  circumcision,  cutting  the  frenum  linguae,  or,  later,  the 
extraction  of  a  tooth,  yet  the  bleeding  may  occur  spontaneously  from  any 
surface. 

Hemorrhages  into  and  around  the  joints  may  occasion  painful  swell- 
ing, with  local  heat  and  tenderness.  The  joints  may  be  attacked  succes- 
sively, the  larger — as  the  hip,  knee,  ankle,  shoulder,  and  elbow — being 
the  more  frequently  the  seat  of  disease.  The  affected  joints  are  first" 
immobilized  by  the  pain,  and  later,  after  more  or  less  complete  reab- 
sorption,  motion  is  limited  by  pseudoankylosis,  due  to  adhesions  from 
fibrous  bands.  Still  later,  true  ankylosis  may  follow  from  the  formation 
of  exostoses  about  the  joint.  The  articular  hemorrhages  recur,  after 
months  or  years,  into  the  same  or  other  joints,  pain  and  sometimes 
rise  of  temperature  preceding.  It  is  claimed  that  in  many  cases  spon- 
taneous hemorrhages  are  preceded  by  prodromes — as  exhilaration  of 
spirits,  or  a  sense  of  plethora — and  that  the  bleeders  experience  relief 
after  a  moderate  loss  of  blood.  Any  considerable  hemorrhage,  as  in 
other  children,  is  followed  by  the  anemia  of  exsanguination.  Death 
has  resulted  from  trifling  lesions,  and  the  diathesis  positively  centra- 
indicates  any  surgical  operation.  The  coagulation  of  the  blood  is  much 
retarded. 

Diagnosis. — The  diagnosis  is  not  difficult.  The  heredity,  when  known, 
the  obstinate  bleeding  from  slight  lesions,  the  extravasations  from  bruises, 
and  the  joint  hemorrhages,  all  unmistakably  stamp  the  bleeder. 


508  DISEASES    OF    THE    BLOOD 

Scurvy,  rheumatic  and  hemorrhagic  purpura,  rheumatism,  and  tuber- 
cular disease  of  the  joints,  have  many  symptoms  in  common ;  but  a  care- 
ful study  of  the  history  as  to  heredity  and  previous  hemorrhages,  as  well 
as  diet,  will  clear  up  the  diagnosis. 

No  specific  treatment  is  known.  For  the  local  hemorrhages,  pressure, 
ice,  styptic  applications  of  sulphate  of  iron,  and  suprarenal  extract,  have 
all  been  used  with  varying  success.  Ligatures  are  unavailing,  as  the 
oozing  is  capillary.  Calcium  chloride  has  been  given  internally  for  a 
long  period  to  increase  the  coagulability  of  the  blood.  For  the  same 
purpose  gelatin,  in  from  two  to  five  per  cent,  solution,  by  hypodermic 
injection,  clysters,  or  by  mouth,  has  been  tried.  It  has  seemed  to  be 
effective  in  some  cases,  but  the  increasing  number  of  reports  of  tetanus, 
in  spite  of  antiseptic  precautions,  have  discouraged  the  hypodermic  use 
of  this  agent.  Stypticin  has  been  highly  recommended  by  some  writers, 
but  clinical  evidence  is  still  too  limited  to  warrant  its  use  in  young 
children. 

After  the  hemorrhages  have  been  checked,  tonic  and  reconstructive 
treatment  should  be  carried  out  to  overcome  angemia. 

PURPURA. 

From  our  present  knowledge  purpura  should  not  be  classed  as  a 
blood  disease.     In  fact,  it  is  not  entitled  to  the  rank  of  a  disease  but 


Fig.  197. — Post-diphtheritic  eruption.    Antitoxin  was  not  used.    (Dr.  J.  C.  Cook.) 

appears  as  a  symptom,  the  underlying  cause  of  which  is  still  unknown. 
The  term  is  applied  to  all  conditions  in  which  there  are  extravasations 
of  blood  into  the  skin  and  mucous  membranes.  These  appear  as  small, 
discrete,  pinhead  red  spots  (petechias)  which  do  not  disappear  on  press- 
ure.   It  may  involve  larger  areas  of  the  cutis  vera  (ecchymoses),  or  may 


PURPURA 


509 


form  collections  of  blood  in  the  deeper  tissues  ( ham  atom  at  a  J ,  which 
appear  as  fluctuating  tumors.  No  etiologic  classification  is  possible 
so  long  as  the  cause  is  not  known,  hence  classifications  in  vogue  are 
based  upon  either  associate  conditions  or  variations  in  symptoms  and 
severity. 

It  may  occur  as  an  accompaniment  or  sequel  of  any  of  the  acute  in- 
fectious fevers, — as  variola,  measles,  diphtheria  (Fig.  197),  influenza, 
gastro-enteritis,  sepsis,  scarlatina,  or  rheumatism  (Schonlein?s  disease 
(Fig.  198),  peliosis  rheumatica),  during  the  course  of  which  its  ap- 
pearance has  been  regarded  as  adding  gravity  to  the  prognosis.  Pur- 
pura of  the  integument  occasionally 
precedes  or  accompanies  hemorrhages, 
more  or  less  extensive,  from  the 
mucosa  of  the  nose,  mouth,  or  diges- 
tive and  urinary  tracts,  as  in  morbus 
maculosus  Werlhofii. 

Occasionally  the  extravasation  may 
occur  in  the  structure  of  the  walls  of 
the  bowels  beneath  the  mucosa,  giving 
rise  to  acute  pain,  local  tumefaction, 
and  spasm  of  adjacent  portions,  di- 
minishing the  lumen  of  the  intestine. 
Vomiting  may  be  stercoraceous  from 
reversed  peristalsis,  as  in  Henoch's 
purpura.  In  this  variety  there  is  hem- 
aturia and  often  effusion  of  blood  in 
and  around  the  joints,  in  which  respect 
it  resembles  one  phase  of  haemophilia. 
Frequently,  aside  from  the  skin  erup- 
tions, the  mucosa  of  the  mouth  is  prin- 
cipally involved  with  congested  and 
bleeding  gums,  in  which  form  it  is  very  suggestive  of  scorbutus.  "When 
uncomplicated  with  hemorrhages  from  any  mucous  surface  or  with  con- 
stitutional signs,  and  seen  only  in  the  integument  of  forearms,  legs,  or 
trunk,  as  bright  red  or  purplish  petechia?,  it  is  known  as  purpura  simplex. 
Occasionally  the  eruption  assumes  the  form  of  wheals,  red  or  purplish 
in  color,  and  is  attended  with  pruritus.  It  is  then  known  as  purpura 
urticans.  A  number  of  drugs  and  chemical  agents  produce  purpuric 
extravasations, — as  quinine,  salicylates,  potassium  iodine,  chloral,  mer- 
cury, and  phosphorus.  Decomposed  meat  sometimes  causes  this  erup- 
tion. Rarely  cases  have  been  reported  in  which  collapse  follows  within 
a  few  hours  an  apparently  trivial  eruption  of  petechia3.  Considerable 
quantities  of  blood  are  sometimes  lost  from  the  gastric,  intestinal,  or 
nasal  mucosa?.  This  bleeding  may  be  extremely  intractable.  Purpura 
fulminans  is  the  term  well  applied  to  such  an  attack. 

Etiology. — Various  micro-organisms  have  been  described  as  present 
in  cases  of  purpura.    Some,  it  is  stated,  will  produce  similar  lesions  when 


Fig.  19S.— Peliosis  rheumatica.   (Dr.  J.  C.  West.) 


510  DISEASES    OF    THE    BLOOD 

inoculated  into  lower  animals.  Although  quite  generally  accepted  as  of 
bacterial  origin,  no  constant  organism  has  been  isolated. 

Pathology. — The  only  lesions  peculiar  to  purpura  are  the  petechias 
and  ecchymoses.  The  blood  changes  are  variable,  and  may  depend  on 
other  causes.  Changes  in  vessel  walls  and  adjacent  tissues  vary  in  dif- 
ferent cases,  some  showing  a  tendency  to  necrotic  processes.  Some  ob- 
servers have  found  the  proportion  of  blood  constituents  normal,  until 
altered  by  the  effects  of  repeated  hemorrhages. 

The  duration  may  vary  from  one  to  many  weeks,  with  a  tendency  to 
recurrence,  the  eruption  appearing  in  crops. 

Diagnosis. — From  scurvy  the  diagnosis  is  sometimes  difficult,  espe- 
cially in  purpuric  extravasations  beneath  the  periosteum,  which,  from 
their  location,  give  rise  to  pain.  The  history  of  the  feeding  and  the 
effects  of  vegetable  acids  will  clear  the  diagnosis.  The  hemorrhages 
occurring  in  leukaemia  and  pernicious  anaemia  may  strongly  resemble 
those  of  purpura.  Examination  of  the  blood  would  show  the  character- 
istic findings  of  these  diseases.  Insect-bites  may  always  be  excluded  by 
the  central  puncture  and  the  excoriations  due  to  pruritus.  Henoch's 
purpura  has  been  mistaken  for  intestinal  obstruction  from  the  acute 
pain,  stercoraceous  vomiting,  and  bloody  stools.  A  careful  examination 
of  the  skin  and  mucous  membrane,  and  review  of  the  history  for  erup- 
tions or  arthritic  symptoms,  may  prevent  useless  laparotomy.  Old 
lesions  of  erythema  nodosum  may  simulate  purpuric  ecchymoses,  but 
location  and  tenderness  on  pressure  reveal  the  nature  of  the  disease. 

Prognosis. — The  prognosis  should  be  guarded,  as  it  varies  with  the 
character  of  the  attack.  This  may  vary  from  a  simple  eruption,  with  no 
other  symptoms,  to  a  fulminating  seizure,  with  fatal  hemorrhages,  within 
twelve  hours.  Cases  are  reported  in  which  purpuric  attacks  have  been 
followed,  more  or  less  remotely,  by  chronic  nephritis. 

Treatment. — Since  the  danger  is  from  extensive  hemorrhage,  the 
treatment  is  directed  to  its  control.  Keeping  the  child  warm  and  quiet 
in  bed  will  lessen  this  tendency.  The  difficulty  of  diagnosis  from  scor- 
butus has  led  to  the  routine  administration  of  vegetable  acids,  some- 
times with  apparent  benefit.  If  severe  intestinal  symptoms  are  present, 
food  should  be  restricted  to  a  bland  diet,  or  withheld  entirely  until  the 
dangerous  hemorrhages  have  ceased.  Ice  may  be  given.  Subgallate  of 
bismuth,  tannic  acid,  tannigen,  calcium  chloride,  ergot,  and  suprarenal 
extract,  especially  the  last,  have  been  of  undoubted  benefit.  In  grave 
cases,  maximum  doses  are  indicated.  In  one  instance  the  administration 
of  twenty-drop  doses  every  hour  of  adrenalin  solution  (1:1000)  to 
an  apparently  moribund  child  of  five  years  was  followed  by  recovery. 
To  control  the  pain  of  abdominal  crises  tincture  of  opium  in  starch 
enema,  or  morphine  hyperdermically,  may  be  necessary.  Concentrated 
proteids,  as  meat  juice,  predigested  foods,  and  milk,  are  indicated  for  the 
apepsia  due  to  the  extreme  anaemia.  A  hydraemic  condition  indicates  iron 
to  increase  the  haemoglobin,  and  calcium  chloride  for  its  effect  on  the 
coagulability  of  the  blood. 


SPINAL    CARIES  511 

DISEASES    OF    THE    BONES    AND    JOINTS. 

Like  the  soft  tissues,  bones  are  subject  to  inflammatory  hyperplastic 
and  necrotic  changes  with  resultant  pus  formation,  overgrowth,  or  caries, 
as  the  case  may  be. 

The  disease  may  begin  as  a  supra-  or  sub-periostitis ;  in  the  epiphysis 
as  a  chondritis  or  osteochondritis;  in  the  epiphyseal  line  as  an  epiphy- 
sitis ;  in  the  head  of  the  bone  as  an  osteitis ;  in  the  substance  of  the  shaft 
as  an  osteomyelitis,  or  in  the  articulation  as  a  synovitis.  In  any  case 
the  inflammation  may  extend  by  contiguity  of  structure,  by  infection 
through  the  lymphatics,  or  by  cutting  off  the  circulation,  causing  death 
of  parts. 

The  infecting  agent  may  be  any  one  of  the  pyogenic  organisms  at- 
tacking a  part  anatomically  favorable,  as  one  in  which  circulation  and 
resistance  have  been  disturbed  by  trauma,  passive  congestion,  or  lowered 
nutrition. 

Since  by  far  the  most  frequent  causes  of  bone  and  joint  lesions  in 
childhood  are  tuberculosis  and  syphilis,  only  such  disorders  will  be 
discussed  here,  space  allowing  mention  only  of  the  commonest  forms. 
It  should  be  borne  in  mind  that  in  whatever  of  the  above-named  tissues 
the  infection  first  occurs,  it  may  end  in  the  involvement  of  any  or  all, 
so  that  abscess  formation,  joint  involvement,  bony  necrosis  with  seques- 
tration, rarefication,  fistula  formation,  or  extensive  pus  burrowing  in  soft 
tissues,  may  be  the  result. 

The  most  frequent  sites  of  these  diseases  are  in  the  long  bones  (their 
proximal  epiphyses  and  adjacent  articulations),  and  in  the  segments  of 
the  vertebral  column. 

Although  the  treatment  of  these  diseases  and  of  their  resultant  de- 
formities should  be  relegated  to  the  orthopaedic  surgeon,  their  early  diag- 
nosis usually  falls  within  the  province  of  the  family  physician,  hence  a 
few  will  be  taken  up  briefly  under  the  classes  of  tubercular  and  syphilitic 
lesions. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS. 

SPINAL    CARIES    (POTT'S    DISEASE)  ;     SPONDYLITIS. 

Spinal  caries  usually  begins  in  the  anterior  portion  of  the  body  of 
a  vertebra,  at  its  epiphyseal  line  or  in  the  intervertebral  cartilage  and 
involves,  if  allowed  to  proceed,  two  or  more  contiguous  vertebra?.  Xo 
portion  of  the  column  is  exempt,  but  the  most  common  site  is  the  mid- 
dorsal  region.  A  large  number  of  cases,  reduced  to  percentages,  gives 
the  following  as  the  relative  frequency  of  location :  cervical,  10 ;  upper 
dorsal,  50:   lower  dorsal,  20;   lumbar,  18;   sacral,  2. 

Pott's  disease,  although  it  may  occur  in  adults,  is  essentially  peculiar 
to  childhood  and  is  rare  before  the  third  year.  The  bodies  of  the  affected 
vertebra1  soften  by  caseous  degeneration,  rarefication,  or  necrosis  with 


512     TUBERCULOUS  DISEASE   OF  BONES  AND  JOINTS 


suppuration,  which  may  be  slight  or  extensive.  Adjacent  structures  are 
occasionally  involved  by  inflammation  or  pressure,  giving  rise  to  neu- 
ralgia of  nerve  distributions  or  to  compression  myelitis.  The  vertebral 
bodies  collapse  under  the  superincumbent  pressure,  resulting  in  angular 
deformity,  kyphosis  (gibbous),  which  is  characteristic  of  the  disease 
(Figs.  199  and  200). 

Pus  may  burrow  through  adjacent  tissues,  and  in  cervical  caries 
collect  in  front  (retropharyngeal  abscess,  Fig.  130),  or  find  exit  at  the 

side  of  the  neck.  In  upper 
dorsal  lesions  pus  may  find 
its    way    into    the    posterior 


Fig.  199.— Spinal  caries.     (Dr.  John  Ridlon.) 


Fig.  200.— Spinal  caries,  with  psoas  ab- 
scess pointing  below  Poupart's  ligament. 
(Dr.  John  Ridlon.) 


mediastinum  or  under  the  deep  fascia  of  the  neck  or  back.  Lower  dorsal 
necrosis  frequently  causes  psoas  abscess,  which  points  either  above  or 
below  Poupart's  ligament  (Figs.  200  to  202),  or  a  collection  of  pus  may 
appear  in  the  gluteal  or  sacroiliac  region. 

Symptoms. — Lassitude,  disinclination  to  play,  sometimes  slight  fever, 
fixation  of  the  spinal  column  upon  stooping,  rigidity  of  back  when  the 
child  is  raised  by  the  feet  from  the  dorsal  decubitus,  tenderness  on 
pressure  over  certain  spinus  processes,  boring  pain  in  back,  starting 


SPINAL    CARIES 


513 


pains  in  sleep,  and  neuralgic  pains  in  chest,  abdomen  or  genitals,  are 
among  the  early  symptoms. 

The  attitude  and  movements  of  the  child  are  characteristic.  He 
rests  his  hands  or  elbows  upon  his  knees  in  sitting  (Fig.  203),  and 
walks  with  a  careful,  steady  gait.  In  stooping  to  pick  up  an  object 
he  holds  the  spine  rigid  or  squats  to  reach  it.  These  symptoms,  and 
the  presence  of  gibbous  or  of  pointing  abscess,  render  the  diagnosis 
certain.  In  cervical  and  upper  dorsal  lesions  some  paralysis  of  the 
extremities  occurs  in  about  half  of  the  cases.     Psoas  abscess  induces 


Fig.  201. — Caries  of  upper  dot  sal  vertebrae,  abscess 
pointing  below  scapula.    (Dr.  John  Ridlon.) 


Fig.  202. — Spinal  caries  with  psoas  abscess  pointing 
above  Poupart's  ligament.     (Dr.  John  Ridlon.) 


flexion  of  the  thigh  upon  the  affected  side  with  resistance  to  rotation 
upon  forced  extension. 

Diagnosis. — From  rhachitic  spine,  Pott's  gibbous  is  differentiated  by 
not  disappearing  upon  suspending  the  child  by  the  arms  and  by  the 
tonic  rigidity  of  the  back  muscles.  Rhachitis  is,  moreover,  a  disease  of 
an  earlier  age.  Lateral  and  rotary  spinal  deformities  appear  later  in 
life  than  caries.  Abscesses  from  perinephritis  and  perityphilitis  lack 
the  other  symptoms  of  Pott's  disease  and  run  a  more  acute  course. 
Anaesthetics  and  the  X-ray  may  aid  diagnosis  in  doubtful  cases. 

Prognosis. — The  prognosis  is  good  as  to  life  if  treated  early,  although 
the  danger  of  general  tuberculous  infection  is  imminent.     Usually  some 

33 


514     TUBERCULOUS  DISEASE   OF  BONES  AND  JOINTS 

deformity  results  even  with  early  treatment.    The  course  of  spinal  caries 
is  chronic,  covering  sometimes  two  or  three  years. 

Treatment. — Aside  from  the  constitutional  treatment  for  tuberculosis 
(q.v.),  the  spinal  column  must  be  immobilized  and  the  pressure  removed 
from  the  bodies  of  the  diseased  vertebras.  A  number  of  ingenious 
methods  are  now  in  vogue  applicable  to  lesions  of  different  portions  of 
the  vertebral  column  which  fulfil  the  indications  and  still  allow  the  child 


Fig.  203. — Characteristic  sitting  posture  of  spinal  caries.     (Dr.  John  Ridlon.) 


freedom  of  exercise  and  locomotion.     The  modern  orthopaedic  surgeon 
has  robbed  spondylitis  of  much  of  its  former  terrors. 

HIP  DISEASE — MORBUS   COXARIUS  ;     COXITIS. 

Hip  disease  is  confined  almost  exclusively  to  childhood,  and  begins 
usually  as  an  epiphysitis  of  the  head  of  the  femur,  or  as  an  osteitis  of 
the  femoral  neck.  Like  all  tuberculosis  of  bone  the  location  of  the  lesion 
is  probably  determined  by  trauma.  It  frequently  follows  acute  dis- 
eases,— such  as  measles,  scarlet  fever,  pertussis,  etc.  Contiguous  tissues 
suffer  in  this  femoral  osteochondritis,  so  that  synovitis  and  acetabular 
disease  soon  follow,  or  occasionally  precede,  the  epiphysitis  of  the  femur. 


HIP    DISEASE  515 

Advanced  cases  show  extensive  destruction  of  the  femoral  head  and  neck 
as  well  as  of  the  acetabular  structures  and  pelvic  bones  which  meet  at 
this  point.  Partial  or  complete  luxation  of  the  diminished  head  of  the 
femur  from  the  changed  shallow  socket  is  a  later  feature  of  the  disease, 
while  suppuration  may  lead  to  destruction  of  the  capsule,  and  burrow- 
ing pus  to  abscess  formation  of  greater  or  less  extent.  Fistulas  form 
through  which  spiculae  of  necrosed  bone  are  discharged  with  the  pus. 
The  process  is  chronic,  occupying  months ;   occasionally  acute  and  rapid. 

Symptoms. — Pain  is  a  frequent  symptom  in  the  early  part  of  the 
disease  and  indicates  involvement  of  the  articular  surfaces.  The  various 
sources  of  nerve-supply  to  this  joint  lead  to  peculiar  distribution  of  the 
pains  which  may  appear  in  the  knee,  inner  side,  back  or  front  of  the 
thigh,  any  part  of  the  leg  or  foot,  in  the  buttocks,  or  over  the  joint  itself. 
Tenderness  may  be  absent,  but  pressure  of  the  femoral  head  against  the 
acetabulum  almost  always  causes  pain.  Starting  pains  at  night  are  not 
uncommon,  as  during  sleep  the  muscles  which  immobilized  the  joint  relax 
and  allow  apposition  of  sensitive  parts. 

Usually  the  first  symptom  to  attract  attention  is  limping  or  stumbling, 
for  which  there  is  no  apparent  reason.  The  child  fatigues  easily  and 
prefers  to  sit  or  to  rest  the  affected  leg,  although  marked  lameness  with 
pain  does  not  develop  until  later,  when  it  is  usually  attributed  to  some 
disorder  of  the  knee  joint  because  of  the  pain  in  that  region.  There 
may  be  swelling,  in  acute  attacks  early,  from  effusion  into  the  synovial 
sac.  In  chronic  cases  this  occurs  later  from  suppuration  and  caseation 
in  the  joint  cavity.  The  swelling  may  be  seen  in  front,  just  outside  of 
the  femoral  vessels,  or  posteriorly  filling  out  the  depression  behind  the 
great  trochanter.  The  inguinal  glands  may  be  enlarged  and  occasionally 
suppurate.  Wasting  of  the  limb  begins  early  and  proceeds  rapidly  from 
atrophy  of  both  muscles  and  bone,  although  the  hip  may  appear  full 
and  rounded  from  hyperplasia  and  collections  of  inflammatory  debris 
in  and  around  the  joint. 

Three  features  of  altered  contour  are  most  always  present :  1,  the 
inguinal  groove  is  flattened  and  almost  obliterated  when  the  limb  is  ab- 
ducted with  outward  rotation,  or  deepened  with  adduction  and  inward 
rotation ;  2,  there  is  flattening  of  the  buttock  on  the  affected  side  with 
obliteration  of  the  smaller  gluteal  fold:  3,  the  prominence  of  the  great 
trochanter.  The  apparent  lengthening  of  the  affected  limb  is  due  to 
the  downward  and  forward  tilting  of  the  pelvis,  while  the  limb  shows 
a  characteristic  slight  degree  of  flexion,  abduction,  and  outward  rota- 
tion. Placing  the  child  upon  the  table  and  attempting  passive  move- 
ments shows  the  rigidity  due  to  spasm  of  the  great  muscles  about  the 
joint  which  limits  extreme  extension,  flexion,  abduction  or  adduction. 
In  later  stages  fixidity  may  be  due  to  matting  together  of  the  tissues 
about  the  joint  by  inflammatory  exudate,  and  rarely  by  bony  ankylosis. 
Crepitus  is  sometimes  detected  upon  rotation,  suggesting  erosion  of  the 
head  or  acetabulum.  Rigidity  may  be  so  marked  as  to  require  chloro- 
form to  determine  its  true  nature.     Extension  of  the  affected  thigh  by 


516     TUBERCULOUS  DISEASE   OF  BONES  AND  JOINTS 

force  tilts  the  pelvis  forward,  causing  the  lumbar  spine  to  leave  the  table 
in  a  high-archecl  curve. 

In  the  later  stage  the  limb  is  sharply  flexed,  adducted,  and  rotated 
inward  where  it  is  rigidly  fixed  (Fig.  204),  the  trochanter  lying  close  to 
the  side  of  the  ilium  above  Nelaton's  line,  which  position  shows  shorten- 
ing of  the  limb.  Collections  of  pus  and  sinuses  may  appear  at  various 
points  sometimes  at  long  distances  from  the  hip. 

The  course  of  morbus  coxarius  is  essentially  chronic,  and  with  few 
exceptions  covers  months  and  even  years  in  its  different  stages. 

Diagnosis. — While  advanced  cases  may  hardly  be  mistaken,  the  early 
stage  or  absence  of  history  makes  the  diagnosis  often  extremely  difficult. 
Among  the  disorders  which  simulate  hip- joint  disease  may  be  mentioned 
rheumatic  arthritis,  strain  of  the  joint,  ostitis  or  periostitis  of  the  great 
trochanter  or  upper  end  of  the  femur,  coxa  vara,  sacroiliac  disease,  ab- 
scesses (psoas,  iliac  or  gluteal,  glandular,  perityphilitic,  or  parasig- 
moidal),  syphilitic  synovitis,  injuries  of  the  knee,  hip  dislocation,  separa- 
tion of  the  epiphysis,  fracture  of  the  neck,  poliomyelitis  and  hysteria. 


Fig.  204.— Hip  disease.     (Dr.  John  Ridlon 


The  diagnosis  must  be  made  from  the  history  and  by  exclusion  of 
other  conditions  which  may  interfere  with  the  free,  smooth,  painless 
mobility  of  the  joint. 

Prognosis. — As  a  tuberculous,  suppurative,  wasting  disease,  the  prog- 
nosis is  always  doubtful,  since  many  die  from  extension  of  tubercular 
infection  to  other  parts.  While  life  is  spared  in  the  majority  of  cases, 
permanent  deformities,  such  as  ankylosis  with  rigid  flexion  and  atrophy 
of  the  limb,  are  the  invariable  result  with  a  tendency  to  recurrence  of 
the  disease  upon  the  slightest  injury  to  the  hip  joint.  Early  treatment, 
however,  at  the  hands  of  the  expert  orthopaedist  gives  to  the  prognosis  a 
very  hopeful  tone.  Under  proper  care  and  treatment  from  the  be- 
ginning, resultant  deformity  is  averted  in  a  great  majority  of  cases  and 
the  mortality  lessened  correspondingly. 

Treatment. — Two  methods  of  treatment  have  advocates  for  their  re- 
spective merits, — viz.,  immobilization  of  the  joint  with  continuous  ex- 


KNEE-JOINT    DISEASE 


517 


tension  and  early  excision  of  the  diseased  head  of  the  femur.  In  this 
country  radical  surgery  is  not  popular  save  as  a  last  resort,  after  treat- 
ment by  mechanical  appliance  has  failed  to  arrest  suppuration  and 
bony  necrosis. 

The  disease  is  essentially  surgical  and  should  be  referred  to  the  ortho- 
paedic  specialist.  The  general  treatment  should  follow  that  outlined  for 
tuberculosis  (q.v.). 


KNEE-JOINT    DISEASE — WHITE    SWELLING. 

As  before  stated  tuberculosis  may  attack  any  joint,  the  hip  being 
affected  most  frequently  if  spondylitis  be  omitted.  Next  in  order  of  sus- 
ceptibility is  the  knee  joint,  in  which  the  disease  may  rarely  begin  and 


Fig.  205.— Tuberculous  affection  of  knee  and  elbow  joints.    (Dr.  John  Ridlon.) 

end  as  a  synovitis  or  may  extend  to  the  adjacent  cartilaginous  struc- 
tures, ligaments,  and  epiphyses  or  even  to  the  bone  of  the  diaphysis. 
Inflammatory  foci  in  the  bone  may  be  the  initial  lesion.  The  synovial 
membrane  is  thickened  or  replaced  by  velvety  or  gelatinous  granula- 
tions, or  fungiform  growths,  and  the  cartilages  are  eroded  away  or  pre- 
sent worm-eaten  depressions  filled  with  granulation  and  caseous  tissue. 
The  ligaments  are  thickened  and  give  to  the  joint  the  appearance  of  bony 
enlargement  when  no  real  bony  overgrowth  is  present.  The  synovial  sac 
is  rarely  much  distended  with  fluid,  as  is  the  case  in  simple  acute 
synovitis. 

Tonic  rigidity  of  the  muscles  in  their  efforts  to  immobilize  the  joint 


518     TUBERCULOUS   DISEASE   OF  BOXES  AND  JOINTS 

causes  gradually  increasing  flexion  with  outward  rotation,  finally  result- 
ing in  luxation,  the  femur  overriding  the  tibia,  which  is  flexed  to  a  right 
angle  where  it  becomes  ankylosed.  Ostitis  of  adjacent  parts,  osteochon- 
dritis, and  osteomyelitis  may  occur,  while  pus  burrowing  up  the  femur 
and  down  the  tibia  forms  fistulous  tracts. 

Symptoms. — White  swelling  occurs  most  frequently  in  children 
between  the  third  and  eleventh  years,  and  is  usually  attributed  to  an 
injury. 

The  child  limps  with  slightly  bent  knee  but  usually  there  is  little 
pain  in  the  beginning.  Later  there  may  be  pain  (starting  pains  at  night) 
and  tenderness  on  pressure  over  certain  points.  Examination  shows 
enlargement  of  the  joint  with  atrophy  of  the  leg  and  thigh.  Pressure 
gives  a  doughy  feel  unless  the  rare  effusion  yields  fluctuation  in  the 
synovial  sac.  Months  may  elapse  before  the  knee  is  very  troublesome, 
and  exacerbations  are  not  uncommon  with  intervals  of  quiescence,  usually 
regarded  as  cures  from  some  local  therapeutic  measures.  The  disease, 
if  neglected,  usually  proceeds  to  total  disablement  with  the  character- 
istic triple  deformity,  with  abscesses  and  discharging  fistula?. 

Diagnosis. — Tuberculous  knee  may  be  mistaken  for  arthritis  (simple, 
traumatic,  rheumatic,  gonorrheal  or  syphilitic),  or  for  osteosarcoma  of 
the  lower  end  of  the  femur. 

Treatment. — Immobilization,  fixation,  and  extension  are  the  indica- 
tions, which  may  be  fully  met  by  orthopaedic  appliances  (Fig.  205).  The 
treatment  should  begin  early ;  hence  the  importance  of  early  diagnosis. 
General  treatment  for  tuberculosis  must  never  be  omitted.  Neglected 
cases  require  resection  of  the  joint  or  excision  of  the  knee, — surgical 
procedures  of  no  mean  magnitude. 

DACTYLITIS — CHRONIC   OSTEOMYELITIS;     SPINA  VENTOSA  ;     SPINA 
PEDARTHROCACE. 

The  phalanges  of  the  fingers  and  metacarpal  bones,  and  less  fre- 
quently of  the  toes  and  metatarsals,  are  frequently  the  seat  of  tuber- 
culous osteomyelitis  or  periostitis.  It  usually  develops  between  the 
first  and  third  year,  but  may  be  met  with  later.  The  process  is  one  of 
rarefication  of  the  shaft,  with  bony  deposition  under  the  periosteum, 
until  the  enlarged  bone  is  but  a  shell  containing  caseous  material,  pus, 
fungoid  granulations  and  necrotic  debris. 

To  the  tubercle  bacilli  other  pyogenic  microbes  may  be  added,  the 
skin  may  become  involved,  and  a  discharging  sinus  develop.  Occasion- 
ally resolution  occurs,  but  more  frequently  the  destructive  process  goes 
slowly  on  until  all  bone  is  destroyed,  when  the  process  terminates  with 
cicatricial  contraction  and  deformity.  Frequently  the  disease  extends  to 
adjacent  bones,  especially  in  the  metatarsal  and  metacarpal  forms,  and 
chronic  indolent  sinuses  form  which  discharge  inflammatory  debris  for 
years,  with  remissions  and  recurrences  (Fig.  206). 

Symptoms. — In  a  tuberculous  child  there  is  first  observed  a  painless 
swelling  of  one  of  the  proximal  phalanges,  most  frequently  of  the  hand. 


CHRONIC    POLYARTHRITIS 


519 


The  enlargement  is  smooth,  fusiform,  hard,  and  gradually  increases  from 
month  to  month  without  inconvenience,  occasionally  remaining  station- 
ary, or  appearing  even  to  retrograde.  The  skin,  which  al  firsl  is  freely 
movable,  later  becomes  attached,  reddens,  and  breaks  down,  disclosing 
a  fistula  which  discharges  scantily  for  months  i  Fi<>\  207). 

Prognosis. — The  outcome  depends  upon 
the  presence  or  absence  of  general  tuber- 
cular infection  or  the  extension  of  the  dis- 
ease to  adjacent  tissue. 

Diagnosis. — The  only  disorder  that  re- 
sembles this  disease  is  syphilitic  dactylitis, 
from  which  it  can  be  distinguished  only 
by  confirmatory  indications  of  syphilis. 
Mercurialization  promptly  relieves  syphil- 
itic dactylitis.  Enchondroma  is  harder, 
runs  a  more  chronic  course,  and  does  not 
suppurate. 

Treatment. — General  treatment  for  tu- 
berculosis should  be  instituted.    The  affected 


Fig.  200.— Chronic  tuberculous  sinuses 
of  ankle.    (Dr.  John  Ridlon.) 


Fig.  207.— Tuberculous  dactylitis.     (Dr.  S.  W.  Kelley.) 


part  should  be  put  at  rest  by  a  proper  splint  or  plaster,  with  slight, 
firm  compression.  If  fistulas  form,  the  diseased  bone  should  be  thor- 
oughly scraped  with  as  little  damage  as  possible  to  the  soft  parts,  the 
cavity  filled  with  aristol,  boric  acid  crystals  or  iodized  gauze,  and  dressed 
antiseptically. 


CHRONIC  POLYARTHRITIS,   WITH  SPLENIC  AND   GLANDULAR   ENLARGEMENT. 

Cases  of  chronic  and  recurrent  polyarthritis,  with  enlargement  of 
the  lymph-nodes  and  spleen,  first  described  by  Still  in  1896,  are  occa- 
sionally seen  and  have  been  reported  in  children  as  young  as  three  years. 
It  is  usually  symmetrical,  beginning  with  the  larger  joints.    There  is  an 


520       SYPHILITIC   DISEASES   OF  BONES   AND  JOINTS 

irregular  pyrexia.  The  joint  swelling  is  considerable  and  there  is  no 
grating  on  motion.  Bony  changes  are  not  usually  marked.  There  may 
be  thickening  of  the  capsule  and  occasional  adhesions.  There  is  enlarge- 
ment of  the  lymph-glands  throughout  the  body,  as  well  as  of  the  spleen. 
The  general  appearance  is  suggestive  of  intoxication,  although  no  specific 
organism  has  been  found.  The  blood  findings  are  not  characteristic,  but 
are  simply  those  of  a  secondary  ansemia.  From  recent  reports  there  is 
reason  to  believe  that  these  cases  may  prove  to  be  peculiar  forms  of 
tuberculosis. 

Several  cases  have  been  recorded  in  which  pericardial  adhesions  were 
found.  As  yet  no  treatment  can  be  recommended,  save  that  directed  to 
amelioration  of  the  symptoms. 

SYPHILITIC  DISEASES  OF  THE  BONES  AND  JOINTS. 

ACUTE   EPIPHYSITIS. 

In  hereditary  syphilis  the  bones  and  joints  frequently  furnish  the 
first  lesions  of  the  disease.  In  very  young  infants  this  may  appear  in 
the  form  of  enlargements  about  the  ends  of  the  long  bones,  particularly 
of  the  ulna,  radius,  humerus,  metacarpals,  and  phalanges,  and  occasion- 
ally of  the  metatarsi  and  toes. 

These  enlargements  are  due  to  an  epiphysitis  or  periostitis  near  the 
joint  in  which  the  epiphyseal  line  is  involved  and  may  result  in  osteo 
myelitis  of  the  adjacent  end  of  the  shaft,  or  in  a  synovitis  of  the  articula- 
tion. Frequently  the  process  is  confined  for  a  long  period  to  the  epiphy- 
seal junction,  which  undergoes  softening  by  the  formation  of  gelatinous 
and  granulation  material,  with  retardation  of  ossification  and  ultimate 
detachment  of  the  epiphysis.  Pus  may  form  in  this  area,  in  the  epiphy- 
sis, in  the  joint,  or  in  the  end  of  the  bone,  and  burrowing  appear  on  the 
surface  through  fistulous  openings. 

Symptoms. — The  enlargements  may  be  first  discovered  about  the 
lower  end  of  the  ulna,  radius,  humerus,  or  tibia.  Rarely  the  hard  swell- 
ing may  extend  to  the  middle  of  the  shaft,  as  of  the  femur.  Again,  the 
infant  may  cry  when  handled  or  avoid  the  use  of  some  limb  which 
appears  to  be  paralyzed. 

Diagnosis. — In  the  presence  of  a  syphilitic  history  or  of  other  mani- 
festations of  the  disease  the  diagnosis  is  plain.  The  pseudoparalysis  is 
due  to  pain  upon  motion.  Examination  will  sometimes  reveal  a  de- 
tatched  epiphysis  and  manipulation  may  elicit  crepitus.  The  disease 
may  be  mistaken  for  scorbutus  which,  however,  shows  other  symptoms 
of  that  disease,  also  a  history  of  dietetic  errors.  The  same  is  true  of 
rickets,  which  the  enlargements  often  simulate  even  to  the  occasional 
beading  of  the  ribs,  presence  of  craniotabes,  and  pain  on  handling.  In 
fact,  differentiation  is  at  times  difficult  until  further  developments  or 
until  the  therapeutic  test  of  treatment  is  made. 

Birth-palsies,  fractures,  and  dislocations  must  be  eliminated  by  care- 
ful examination. 


CHRONIC    OSTEOPERIOSTITIS  521 

The  prognosis  is  fairly  good  if  the  case  is  seen  before  extensive 
suppuration  or  osteomyelitic  processes  have  developed,  to  which  the 
infant  quickly  succumbs.  Destructive  processes  of  the  nasal  and  palate 
bones  have  been  mentioned  under  syphilis. 

An  acute  syphilitic  arthritis  in  infants  is  occasionally  observed  in 
which  the  process  begins  in  the  synovial  sac.  It  may  be  multiple  and 
show  considerable  local  distention  and  pain.  This  arthritis  may  be 
serous  or  purulent.  In  the  latter  case  the  capsule  soon  yields,  with 
resultant  formation  of  diffuse  abscesses  which  open  spontaneously. 

The  treatment  is  antisyphilitic,  to  which  the  acute  epiphysitis  and 
periostitis  yield  promptly  in  children  with  sufficient  vitality  to  secure 
response.  Specific  medication  should  be  supplemented  by  the  best  of 
nourishment  and  general  hygiene.  Sinuses,  pus  cavities  and  bony  necro- 
sis must  be  treated  surgically.  Many  surgeons  favor  early  incision  down 
to  the  bone,  to  be  followed,  if  necessary,  by  free  opening  into  the  bone 
by  trephine  or  gouge  for  the  release  of  pus. 

CHRONIC  OSTEOPERIOSTITIS. 

In  late  hereditary  syphilis,  bone  lesions  develop  much  like  those  of  the 
tertiary  stage  of  the  acquired  disease.  The  favorite  seat  of  these  lesions 
is  the  periosteum  and  its  vicinity.  The  processes  are  very  chronic,  cover- 
ing years  of  time,  and  rarely  develop  before  the  fifth  year  and  fre- 
quently after  the  tenth  year.  Whether  it  begins  upon  or  beneath  the 
periosteum,  that  membrane  becomes  thickened,  sometimes  enormously, 
and  deposits  new  bone  beneath  its  surface,  resulting  in  changes  in  the 
contour  of  the  underlying  structure.  This  form  affects  principally  the 
diaphysis  of  the  long  bones,  most  frequently  the  tibia,  which  becomes 
curved  anteriorly,  or  anterior-laterally,  in  a  characteristic  deformity 
known  as  "sword  leg."  Other  bones,  as  the  ulna,  radius,  and  humerus 
may  be  affected,  and  the  circumscribed  bossse  seen  upon  the  cranium  in 
late  syphilis  are  due  to  subperiosteal  deposits.  These  thickenings  occa- 
sionally appear  near  the  ends  of  the  long  bones  as  osseous  tumors  or 
nodes  which  are  liable  to  necrotic  softening,  with  fistula  formation  and 
discharge  of  pus  and  bony  detritus.  The  process  of  local  bony  thicken- 
ing may  go  on  for  years  with  increasing  deformity,  some  tenderness, 
and  little  pain.     There  may  be  acute  night  pains. 

Periosteal  gummata  may  break  down  and  lead  to  single  or  multiple 
'  discharging  lesions,  which  persist  until  the  bone  sequestrum  at  their 
base  is  entirely  evacuated,   after  which  they  heal,  leaving  permanent 
characteristic  scars. 

Allied  to  chronic  periostitis  is  dactylitis  (spina  ventosa\  which  is 
occasionally  due  to  syphilis.  It  can  rarely  be  diagnosed  from  the  tuber- 
culous lesion  except  by  the  presence  of  other  symptoms  and  specific  his- 
tory. The  course  is  essentially  chronic  and  painless,  with  ultimate  in- 
volvement of  the  skin  and  necrosis  of  the  rarefied  bony  shell. 

Diagnosis. — Rickets  and  tuberculosis  are  to  be  excluded,  although  the 
child  may  suffer  from  the  three  diseases  concurrently.      Rhachitic  de- 


522       SYPHILITIC   DISEASES    OF   BOXES   AXD   JOINTS 

formities  of  the  legs  show  bending  rather  than  irregular  osseous  hyper- 
plasia, and  are  rarely  complicated  with  discharging  ulcers  and  sinuses. 
Further,  the  nodular  terminal  enlargements  are  symmetrical  and  affect 
all  the  long  bones,  whereas  in  syphilis  the  ulna  may  show  thickening 
from  which  the  radius  is  free,  and  vice  versa. 

Syphilis  at  this  stage  rarely  fails  to  give  other  evidences — as  kera- 
titis, Hutchinson 's  teeth,  etc. — while  the  persistent  boring  pains  at  night 
are  almost  pathognomonic. 

Treatment. — Osteoperiostitis  is  the  most  obstinate  form  of  hereditary 
syphilis  and  rarely  yields  to  mercury  alone.  Full  doses  of  iodides  long 
continued  may  be  necessary  to  arrest  its  progress.  Both  specific  and 
tonic  (mixed  treatment)  are  indicated,  with  special  attention  to  hygiene. 
Xeerotic,  fistulous,  and  suppurating  lesions  call  for  surgical  treatment, 
and  bony  sequestra  may  require  the  chisel. 

Opiates  may  be  necessary  for  the  temporary  relief  of  the  night  pains, 
which  yield  permanently,  however,  only  to  full  doses  of  the  iodides. 
Special  care  of  the  stomach  is  necessary,  as  medication  must  necessarily 
be  long  continued. 

ACUTE   OSTEOMYELITIS. 

Acute  osteomyelitis  of  infancy,  unfortunately,  is  not  a  very  rare 
disease.  It  has  been  described  under  the  terms  acute  arthritis  of  infants, 
acute  purulent  synovitis  of  infants,  and  acute  epiphysitis, — unfortunate 
terms  in  their  failure  to  suggest  the  site  of  the  original  lesion,  which  is 
in  the  marrow  of  the  shaft,  usually,  though  not  always,  in  close  proximity 
to  the  epiphysis.  It  may  occur  at  any  age  in  infancy  and  childhood 
with  a  marked  predisposition  for  the  early  suckling  period.  Its  etiology 
includes  a  variety  of  the  pus  organisms,  the  staphylococcus  evidently 
predominating.  Infection  may  occur  through  the  cord  of  the  unhealed 
umbilicus,  or  any  abrasions  of  skin  or  mucous  membranes  in  older 
children. 

The  onset  is  sudden,  with  symptoms  of  an  acute  infection,  vomiting, 
pyrexia,  localized  swelling,  and  pain  in  the  affected  part.  The  com- 
monest sites  are  the  femur,  tibia,  humerus,  radius,  and  ulna. 

The  course  is  rapid,  with  extensive  burrowing  of  pus  if  not  early 
released.  The  epiphysis  may  be  early  involved  and  is  loosened  from  the 
shaft  by  the  extensive  suppuration,  which  quickly  invades  the  synovial 
cavity.  This  is  seen  especially' in  those  joints  where  the  epiphyseal  line 
lies  within  the  capsule,  as  in  the  hip  and  shoulder.  Multiple  lesions  may 
appear  in  different  parts  of  the  body.  The  clinical  picture  is  that  of 
acute  pyaemia  with  high  temperature,  local  oedema,  and  extensive  sup- 
puration. 

The  early  mortality  of  neglected  osteomyelitis  makes  a  prompt  diag- 
nosis imperative.  It  is  distinguished  from  scorbutus  by  the  pyrexia  and 
absence  of  hemorrhages;  from  rheumatic  arthritis  by  the  more  rapid 
onset,  more  pronounced  constitutional  symptoms,  more  marked  leucocy- 
tosis,  early  evidences  of  suppuration,  and  the  fact  that  rheumatism  is 
comparatively  rare  in  young  infants.     From  tuberculous  processes  it  is 


ARTHRITIS    DEFORMANS  523 

differentiated  by  the  fulminating  character  of  the  invasion.  The  possi- 
bility of  gonorrheal  infection  should  be  kept  in  mind,  as  infants  are 
especially  susceptible  to  infection  by  the  gonoeoccus.  Examination  of 
the  vaginal,  urethral,  and  ocular  mucous  membranes  may  ;ii<l  in  diag- 
nosis. Death  may  follow  in  a  few  days  if  not  speedily  relieved  by 
thorough  surgical  measures. 

ARTHRITIS   DEFORMANS. 

As  the  name  implies,  arthritis  deformans  is  a  chronic  progressive 
disorder  affecting  many  of  the  smaller  articulations  and  most  of  the 
larger  ones,  resulting  in  ankylosis  and  deformity.  The  joints  most  fre- 
quently affected  are  the  metacarpophalangeal  (the  thumb  usually  ex- 
cepted), knees,  hips,  ankles,  elbows  and  wrists. 

The  deformity,  when  far  advanced,  particularly  of  the  phalangeal 
articulations,  resembles  subluxations,  with  additional  enlargements 
around  the  head  of  the  bones.  This  deformity  is  exaggerated  by  extreme 
wasting  of  adjacent  muscles.  There  is  a  tendency  to  ankylosis  after 
gradually  increasing  limitations  of  motion,  so  that  the  victim,  with  un- 
impaired mental  and  vital  functions,  becomes  quite  helpless.  The  limbs 
become  gradually  rigid  in  positions  of  moderate  flexion. 

The  etiology  is  still  obscure,  but,  whether  of  neuropathic  or  of  in- 
fectious origin,  it  is  probably  a  complex  condition  in  which  the  varying 
results  are  brought  about  by  different  causes — as  inflammatory,  trophic, 
and  mechanical.  Moreover,  under  the  title  of  arthritis  deformans,  un- 
doubtedly different  observers  have  described  a  variety  of  disorders  vary- 
ing in  their  etiology.  For  this  reason  the  descriptions  of  the  onset  vary 
from  an  acute  synovitis  or  from  a  periarticular  inflammation  to  a  grad- 
ual, almost  imperceptible,  beginning  of  mere  stiffness. 

Although  most  frequently  seen  in  young  adults,  it  occasionally  begins 
in  childhood,  after  the  fifth  year,  notably  among  poorly  nourished 
victims  of  malhygiene,  whose  family  histories  show  gout,  rheumatism, 
or  allied  disorders.  In  these  patients  freedom  from  cardiac  involvement 
renders  doubtful  the  diagnosis  of  rheumatism,  and,  from  the  absence  of 
urates  in  joints,  that  of  gout ;  moreover,  the  treatment  suitable  for  either 
of  these  affections  is  not  beneficial.  The  disease,  though  not  fatal  to  life, 
is  refractory  and  influences  general  nutrition  in  childhood  through  en- 
forced confinement.  Amelioration  from  the  pain  during  acute  attacks 
may  be  secured  by  heat  and  anodyne  embrocations,  with  massage  of  adja- 
cent muscles.  Later,  electricity  and  passive  motion  aid  in  retarding  com- 
plete contractures  and  ankylosis.  Hot-sand  baths  are  always  grateful 
and  result  in  transient  benefit. 

Arsenic,  iron,  and  cod-liver  oil  are  reconnnended  for  the  general 
nutrition.  Claimants  are  not  wanting  for  beneficial  results  in  the  arrest 
of  the  progress  of  the  disease  by  means  of  these  agents. 

In  so  far  as  arthritis  deformans  selects  the  impoverished,  the  prophy- 
lactic indications  are  plainly  in  the  maintenance  of  nutrition  and  avoid- 
ance of  unfavorable  conditions. 


CHAPTER    XIII 
DISEASES    OF    THE    EYE 

AFFECTIONS   OF    THE   LIDS 

The  following  conditions  are  common  among  children,  and  some  are 
peculiar  to  the  early  years.  Xo  special  instruments  are  required  for 
their  diagnosis  or  treatment,  and  such  cases  must  often  be  cared  for  by 
the  family  physician. 

Blepharitis  is  the  commonest  affection  of  the  lids.  It  is  seen  in  two 
forms, — the  simple  and  ulcerative.  Both  forms  are  apt  to  be  very 
chronic  and  the  ulcerative  may  follow  the  simple  form. 

Symptoms. — In  the  simple  form  the  margins  of  the  lids  are  slightly 
reddened  and  swollen,  and  small  whitish  scales  are  seen  amongst  the 
lashes.    The  latter  may  be  pulled  out  easily,  but  they  are  soon  replaced. 

In  the  ulcerative  form  the  edges  of  the  lids  are  redder  and  more 
swollen,  and  the  lashes  are  glued  together  with  yellowish-brown  crusts. 
When  these  crusts  are  removed  small  ulcers  are  seen  about  the  roots  of 
the  lashes.  The  hair  follicles  are  infected,  the  roots  of  the  cilia  are 
destroyed,  and  the  cilia  fall  out,  not  to  be  replaced  again.  The  lashes 
which  remain  are  apt  to  be  misdirected  from  the  distortion  of  the  lid 
margin  due  to  scar  contraction  (trichiasis).  In  both  forms  of  blephari- 
tis we  have  itching,  soreness,  tearing,  and  photophobia,  in  proportion  to 
the  severity  of  the  inflammation. 

Etiology. — In  infancy  the  commonest  cause  is  malnutrition  and  poor 
hygiene.  The  disease  may  follow  the  exanthems,  especially  measles  and 
conjunctivitis  of  any  form.  In  children  of  school  age  the  same  causes 
operate,  but  eye-strain  is  a  very  common  and  potent  factor. 

Treatment  should  be  first  directed  to  securing  good  nutrition  and 
perfect  cleanliness.  The  crusts  should  be  gently  removed  once  or  twice 
a  day  by  the  application  of  warm  water  softened  by  the  addition  of 
powdered  borax,  one  teaspoonful  to  the  quart.  When  the  lids  are  quite 
clean  and  free  from  scales  and  crusts,  they  should  be  dried  and  an 
ointment  applied.  One  made  from  yellow  oxide  of  mercury  (only  that 
from  reliable  chemists  should  be  used),  five  grains  to  the  ounce  of 
vaseline  (0.3-32  Gm.),  is  the  best.  In  the  ulcerative  form  it  is  usually 
necessary  to  use,  occasionally  at  least,  a  stronger  antiseptic.  A  one  per 
cent,  solution  of  nitrate  of  silver,  carefully  applied  to  the  ulcers  only, 
is  a  favorite.  Argyrol  in  twenty-five  per  cent,  solution  is  better  and 
may  be  used  freely.  It  should  be  rubbed  in  well  with  a  cotton  swab. 
In  patients  who  are  using  the  eyes  for  reading,  etc.,  the  eyes  should  be 
examined  for  errors  of  refraction  and  the  correcting  glasses  worn  con- 
stantly. 
524 


AFFECTIONS    OF    THE    EYELIDS  525 

Hordeolum,  or  Stye,  is  a  circumscribed  inflammation  of  the  lid 
margin  usually  due  to  an  infection  of  a  hair  ±*o  1 1  i « •  I « • . 

The  subjective  symptoms  are  those  of  blepharitis, — pain,  soreness, 
lachrymation,  and  sensitiveness  to  light.  A  red  swelling,  frequently  ac- 
companied by  considerable  oedema  of  the  entire  lid,  finally  points  at  the 
root  of  a  cilium. 

Etiology. — Styes  occur  at  all  ages,  often  in  crops,  and  are  frequently 
associated  with  derangement  of  digestion,  constipation,  and,  in  girls  at 
puberty,  with  menstrual  disorders.  The  congestion  of  the  lids  incident 
to  eye-strain  undoubtedly  acts  as  a  predisposing  cause. 

Treatment. — A  stye  can  often  be  aborted  by  pulling  out  the  affected 
eyelash  and  making  frequent  applications  of  hot  or  very  cold  solution 
of  boric  acid.  When  suppuration  shows  itself  the  pus  should  be  evacu- 
ated by  a  small  horizontal  incision.  A  crop  of  styes  suggests  improve- 
ment in  hygiene  and  the  correction  of  faulty  nutrition  by  regulation  of 
diet  and  the  administration  of  tonics  and  alteratives.  Errors  of  refrac- 
tion should  be  corrected. 

Chalazion  is  an  inflammatory  tumor  of  a  Meibomian  gland  due 
to  infection,  and  is  to  be  differentiated  from  a  stye  by  its  location.  As 
the  glands  involved  are  located  between  the  tarsus  and  the  conjunctiva, 
the  chalazion  first  shows  itself  on  the  inside  of  the  lid,  but  later  as  a 
rounded  tumor  beneath  the  skin.  Small  tumors,  involving  the  ducts  of 
the  glands  only,  sometimes  appear  at  the  lid  margin,  but  should  not  be 
confounded  with  stye  by  a  careful  observer. 

Symptoms. — These  little  tumors  are  not  painful,  except  when  they 
suppurate,  and  are  annoying  chiefly  because  of  the  disfigurement  they 
produce  when  of  large  size,  and  a  certain  amount  of  conjunctival  irri- 
tation. 

Treatment  consists  in  opening  by  incision  through  the  conjunctiva 
and  thorough  curettage,  preferably  with  a  small  serrated  curette.  Appli- 
cations are  usually  a  waste  of  time,  although  a  chalazion  is  sometimes 
seen  to  disappear,  or  become  very  small,  without  treatment.  Crops  of 
chalazia  may  be  due  to  chronic  constipation  and  eye-strain  and  call  for 
examination  of  the  child  for  errors  of  refraction  with  appropriate  treat- 
ment. 

Trichiasis  is  an  inturning  of  the  lashes  so  that  they  rub  against  the 
cornea.    It  is  usually  due  to  cicatricial  deformity  of  the  lid  margin. 

Distichiasis  is  a  double  row  of  lashes,  the  inner  row  being  so  displaced 
as  to  rub  against  the  cornea.  The  condition  is  usually  congenital  and 
is  rare. 

Entropion  is  a  rolling  in  of  the  tarsal  portion  of  the  lid  so  that 
the  lashes  rub  against  the  cornea,  The  commonest  cause  is  cicatricial 
contraction  of  the  conjunctiva  from  old  trachoma,  burns,  etc.  It  may  be 
spasmodic. 

Symptoms. — These  three  conditions  cause  mechanical  irritation  and 
inflammation  of  the  cornea  with  pain,  lachrymation,  photophobia,  ulcer- 
ation and  opacities. 


526  DISEASES    OF    THE    EYE 

Treatment. — The  cilia  may  be  removed  by  epilation  or  electrolysis, 
or  an  operation  may  be  done  to  restore  the  position  of  the  lid  margin. 

Ectropion  consists  of  an  eversion  of  the  lid,  leaving  the  eyeball  more 
or  less  exposed,  causing  irritation,  inflammation,  and  in  some  cases 
ulceration  of  the  cornea  with  pain,  lachrymation  and  photophobia. 

Etiology. — It  may  occur  as  an  acute  affection,  in  children,  accom- 
panying conjunctivitis  and  inflammation  of  the  cornea,  and  is  almost 
always  present  in  facial  paralysis.  It  is  usually  due,  however,  to  scar 
contraction,  the  result  of  burns  and  other  injuries  of  the  skin  of  the 
lids  and  neighboring  parts  of  the  face. 

Treatment  depends  upon  the  variety  and  cause  of  the  affection.  Some 
cases  disappear  quickly  when  the  cause  is  removed,  but  the  cicatricial 
form  yields  only  to  operation. 

Ptosis,  as  seen  in  children,  is  usually  congenital  and  is  due  to  an 
imperfect  development  of  the  levator  muscle.  It  may  also  be  due  to 
mechanical  causes, — as  tumors,  accumulation  of  fat,  hypertrophy  of 
connective  tissue,   and  to  syphilis  and  rheumatism. 

Treatment. — The  congenital  variety  can  be  relieved  by  operation 
only.  Cases  due  to  syphilis  and  rheumatism  usually  yield  to  appropriate 
medication. 

Injuries  of  the  eyelids  are  quite  common  in  children  and  include 
contusions,  wounds,  insect-bites  and  burns. 

Ecchymosis  is  usually  due  to  a  blow  over  the  eye  or  at  the  root  of 
the  nose.  It  may  follow  a  fracture  at  the  base  of  the  skull  and  has 
occurred  after  a  violent  paroxysm  of  whooping-cough  from  the  break- 
ing of  a  small  vessel. 

Treatment  consists  in  the  application  of  hot  compresses  and  gentle 
massage  with  a  bland  ointment. 

Insect-bites  commonly  cause  great  swelling,  which  can  usually  be 
controlled  by  iced  compresses  and  a  soothing  ointment, — borated  vaseline, 
cold  cream,  camphor-ice,  etc. 

Burns  of  the  lids  are  of  serious  importance  because  of  the  great 
deformity  which  frequently  follows. 

Treatment. — After  thorough  but  gentle  cleansing  they  should  be 
well  covered  with  sterile  vaseline  and  a  moist  boric  dressing.  If  there  is 
much  discharge  it  is  well  to  renew  the  dressing  twice  a  day.  As  soon 
as  the  surfaces  granulate  Thiersch's  grafts  should  be  applied. 

Blepharospasm  is  an  annoying  condition.  It  may  vary  from  a  slight 
intermittent  contraction  of  a  few  fibres  of  the  orbicularis  to  a  strong 
tonic  spasm  which  makes  it  difficult  to  force  the  eye  open  for  examina- 
tion. The  simple  twitching  of  the  lids  seen  in  patients  suffering  from 
eye-strain  and  chronic  conjunctivitis  is  usually  relieved  by  the  removal 
of  the  cause.  A  more  serious  form,  accompanied  by  contractions  of  the 
facial  muscles,  is  very  common  in  nervous  school  children — "  habit 
spasm"  or  "  habit  chorea."  It  is  usually  initiated  by  eye-strain  and 
follicular  conjunctivitis,  and  is  relieved  by  appropriate  treatment  if  re- 
sorted to  early;    but  if  treatment  be  delayed  until  the  vicious  habit  is 


AFFECTIONS    OF    THE    EYELIDS  527 

firmly  fixed  it  is  an  exceedingly  stubborn  affection.  Tonic  spasm  is  a 
persistent  cramp  of  the  orbicularis  muscle,  and  may  be  caused  by  the 
irritation  of  a  foreign  body,  by  phlyctenular  conjunctivitis,  or  keratitis. 

Treatment  consists  in  removal  of  all  sources  of  irritation,  attention 
to  the  general  health,  and  the  exhibition  of  gelsemium  or  conium  in  re- 
fractory cases. 

Conjunctivitis. — Inflammations  of  the  conjunctiva  are  very  common 
in  childhood  and  their  complications  and  sequeke  sometimes  cause  per- 
manent impairment  or  loss  of  sight.  Various  clinical  and  etiological 
classifications  will  be  found  in  text  books  on  ophthalmology,  but  the 
very  simplest  will  serve  best  the  purposes  of  this  chapter. 

Acute  Catarrhal  Conjunctivitis  is  characterized  by  a  rather 
sudden  onset  and  a  mucoid  or  mucopurulent  discharge. 

Symptoms. — The  conjunctiva  of  the  lids  and  fornix  is  very  red  and 
swollen  and  in  some  cases  there  is  injection  and  oedema  of  the  bulbar 
conjunctiva,  with  small  hemorrhages  and  cedema  of  the  lids.  The  more 
severe  the  inflammation  the  more  pus  and  fibrinous  exudate  is  found  in 
the  discharge,  and  the  greater  the  accumulation  gluing  the  lids  together 
during  sleep.  The  patient  will  complain,  if  at  all,  of  itching,  smarting, 
or  burning  of  the  lids,  and  usually  of  the  sensation  of  foreign  bodies 
in  the  eye.  There  is  slight  photophobia,  and  some  blurring  of  vision 
from  the  discharge  covering  the  cornea.  Attempts  to  use  the  eyes 
aggravate  the  symptoms.  When  the  disease  occurs  in  debilitated  patients 
and  is  neglected,  infiltration  and  ulceration  of  the  cornea  may  occur  and 
the  opaque  scar  resulting  from  the  healing  of  the  ulcer  may  impair  the 
sight.  As  a  rule,  however,  the  disease  tends  to  recovery  in  a  week  or 
two,  if  the  eyes  are  kept  clean  and  not  irritated. 

Etiology. — The  conjunctival  sac  always  contains  micro-organisms 
from  the  air,  which  may  become  pathogenic  and  increase  in  numbers  with 
irritation  and  increased  secretion  from  the  conjunctiva.  Conjunctivitis 
may  occur  at  any  time  of  the  year  from  exposure  to  wind,  dust,  smoke, 
etc.,  but  is  more  common  in  the  spring  and  fall.  It  may  follow  direct 
infection  from  soiled  fingers,  towels,  or  handkerchiefs  of  those  suffering 
from  the  disease,  and  it  is  best  to  regard  any  discharge  from  an  in- 
flamed eye  as  contagious.  Catarrhal  conjunctivitis  is  a  common  accom- 
paniment of  measles,  scarlatina,  smallpox,  impetigo  contagiosa,  or  eczema. 
It  is  almost  always  associated  with  severe  coryza,  hay-fever  and  influenza, 
and  may  be  a  direct  extension  from  the  inflammation  in  the  nose. 

Treatment. — Much  can  be  accomplished  by  local  applications  to 
shorten  the  duration  of  this  disease,  to  relieve  the  patient's  discomfort, 
and  to  prevent  its  becoming  chronic.  During  the  first  day  or  two  in 
severe  cases  great  relief  may  be  obtained  from  the  use  of  iced  com- 
presses, applied  from  half  an  hour  to  an  hour  three  times  a  day.  These 
are  best  prepared  by  cooling,  on  a  block  of  clean  ice,  pledgets  of  cotton 
saturated  with  boric  acid  solution  and  transferring  a  fresh  one  to  the 
eye  every  three  or  four  minutes.  The  lids  should  be  gently  opened  and 
the  eye  irrigated  from  three  to  six  times  daily  with  a  warm  solution  of 


528  DISEASES    OF    THE    EYE 

boric  acid,  after  which  a  drop  or  two  of  a  twenty-five  per  cent,  solution 
of  argyrol  should  be  instilled.  A  bland  ointment,  thirty  grains  of  boric 
acid  and  one  ounce  of  vaseline  (2-32  Gm.),  applied  to  the  edges  of  the 
lids  at  bedtime,  will  prevent  their  sticking  together  and  may  help  to 
prevent  blepharitis,  a  frequent  complication  in  poorly  nourished  chil- 
dren. If  the  disease  tends  to  become  chronic  the  treatment  for  chronic 
conjunctivitis  should  be  employed. 

Chronic  Conjunctivitis  may  follow  any  of  the  acute  forms  of  the 
disease,  or  it  may  come  on  gradually  as  a  result  of  eye-strain  or  constant 
exposure  to  irritation. 

Symptoms. — The  conjunctiva  is  red  but  not  much  swollen,  and  there 
is  little  change  in  the  amount  or  character  of  the  secretion,  which  may 
even  be  diminished.  The  patient  complains  of  itching,  burning,  and 
dryness  of  the  lids  and  the  eyes  tire  easily,  especially  when  used  in  the 
evening. 

Treatment. — Errors  of  refraction  should  be  corrected  and  the  lenses 
worn  constantly.  The  habits  of  eye-work  and  the  environment  must  be 
looked  after,  and  locally  the  prolonged  and  faithful  use  of  astringent 
solutions  insisted  upon  until  all  symptoms  are  relieved.  Zinc  acetate, 
one-fifth  to  one  per  cent. ;  silver  nitrate,  one-tenth  to  one-fifth  per  cent. ; 
alum,  one-fifth  to  one-half  per  cent.,  and  the  yellow  oxide  of  mercury 
ointment,  one  to  two  per  cent,  may  be  tried  in  succession.  The  treatment 
must  be  changed  every  two  or  three  weeks. 

Follicular  Conjunctivitis  is  a  chronic  inflammation  in  which  the 
conjunctiva,  especially  of  the  lower  lid  and  fornix,  is  studded  with 
round,  pinkish  elevations  consisting  of  little  masses  of  lymphoid  tissue 
resembling  the  granules  of  trachoma,  except  that  they  disappear  and 
leave  no  scars. 

Etiology. — The  cause  of  this  disease  is  unknown,  but  it  is  peculiar 
to  children  and  young  people.  Poor  hygiene,  indoor  life,  and  bad  nutri- 
tion seem  to  be  predisposing  causes. 

Symptoms. — In  mild  cases  the  patients  frequently  do  not  complain 
and  the  discovery  of  the  condition  is  accidental,  but  usually  the  symp- 
toms are  those  of  ordinary,  chronic  conjunctivitis. 

The  treatment  is  also  that  of  chronic  conjunctivitis.  If  the  granula- 
tions are  large  and  do  not  disappear  under  the  usual  treatment  they 
may  be  expressed  with  forceps  constructed  for  the  purpose. 

Trachoma  is  a  contagious  form  of  inflammation  of  the  conjunctiva. 
It  is  usually  chronic  and  of  long  duration,  and  is  characterized  by  hyper- 
trophy of  the  conjunctiva,  the  formation  of  "granules,"  with  subse- 
quent cicatricial  changes  in  the  lids  and  vascularization  and  ulceration 
of  the  cornea. 

Symptoms. — Trachoma  may  come  on  insidiously  and  exist  for  months 
without  the  knowledge  of  the  patient,  or  it  may  be  ushered  in  by  an 
acute  inflammation  with  purulent  discharge,  making  the  diagnosis  diffi- 
cult. As  a  rule,  however,  it  manifests  itself  by  photophobia,  lachryma- 
tion,  itching,  pain,  sensation  of  mote  in  the  eye,  and  disturbance  of 


CONJ  UNCTIVITIS  529 

vision.  There  is  swelling  of  the  lids,  drooping  of  the  upper  lid,  and  a 
variable  amount  of  mucopurulent  discharge.  The  conjunctiva  of  the 
lids  and  fornices  is  red,  hypertrophied,  thrown  into  folds  and  studded 
with  granulations.  The  ocular  conjunctiva  is  usually  injected,  and  as 
the  disease  progresses  the  cornea  becomes  infiltrated,  vascular,  rough- 
ened, and  finally  opaque.  The  disappearance  of  the  granules  is  accom- 
panied by  the  displacement  of  the  mucous  membrane  by  glistening  white 
scar-tissue  which  contracts,  obliterating  the  folds  of  the  cul-de-sac  and 
producing  entropion.  The  constant  irritation  of  the  cornea  from  the 
inverted  lashes  keeps  up  the  inflammation  and  ulceration,  prolonging 
the  patient's  suffering.  Unless  this  course  can  be  checked  by  treat- 
ment, the  end  is  blindness  from  cicatrization  of  the  cornea. 

Etiology. — Trachoma  is  not  so  common  among  children  as  in  adult 
life,  but  many  cases  occur  among  the  children  of  the  poor.  It  is  most 
common  among  the  Jews,  Irish,  and  Italians,  but  very  rare  among 
negroes.  The  contagion  is  transmitted  by  contact  and  by  towels,  hand- 
kerchiefs, etc.,  through  the  secretion.  It  spreads  rapidly  in  schools, 
asylums,  and  in  tenements. 

Treatment. — Acute  cases  are  to  be  managed  on  the  principles  laid 
down  for  the  treatment  of  acute  conjunctivitis.  Chronic  cases  are  best 
treated  surgically,  by  the  expression  of  the  granulations,  except  when 
they  are  small  and  there  is  considerable  thickening  of  the  conjunctiva. 
In  these  later  cases  if  there  be  much  discharge  a  two  per  cent,  solution 
of  nitrate  of  silver,  carefully  applied  to  the  everted  lids  in  such  a  way 
as  not  to  come  in  contact  with  the  cornea,  the  excess  being  neutralized 
with  salt  salution,  seems  to  be  the  best  remedy.  If  there  be  little  or  no 
discharge  a  1 :  1000  solution  of  bichloride  of  mercury  or  boroglyceride 
should  be  applied  every  day  or  two  by  the  physician,  the  patient  mean- 
while using  some  efficient  cleansing  measures  several  times  a  day.  The 
patient  with  trachoma  should  be  put  in  the  best  possible  general  condition 
and  should  be  isolated  from  his  fellows,  or  guarded  in  such  a  way  that  he 
cannot  spread  the  disease.  Individual  towels,  basins,  soap,  etc.,  should 
be  the  rule,  and  each  patient  should  have  his  own  bottle  of  drops,  pipette, 
cotton,  and  whatever  else  is  used  about  the  eye  in  all  cases  of  con- 
junctivitis. 

Purulent  Conjunctivitis  may  occur  at  all  ages  and  as  a  result  of 
infection  by  any  of  the  pus-producing  microbes.  The  most  virulent  cases 
of  this  disease  occur  in  babies  born  of  women  with  recent  gonorrhoea, 
although  the  gonococcus  is  found  in  less  than  fifty  per  cent,  of  the  cases. 
The  eyes  are  usually  infected  during  the  passage  of  the  head  through  the 
birth  canal,  but  infection  may  occur  in  utero  when  the  membranes  are 
ruptured  prematurely.  It  may  also  occur  after  birth  by  indirect  con- 
tamination. 

Symptoms. — First  stage :  After  a  period  of  incubation,  never  longer 
than  five  days  unless  from  secondary  infection,  the  conjunctiva  becomes 
red,  the  lids  swell,  and  a  slight  serous  or  mucous  discharge  appears.  The 
eye  is  tender.    This  is  followed  by  greater  swelling  of  the  lids,  chemosis 

34 


530  DISEASES    OF    THE    EYE 

of  the  conjunctiva,  and  slight  constitutional  disturbance.  Second  stage : 
The  swelling  of  the  lids  and  conjunctiva  may  diminish,  the  eye  become 
less  tender,  while  a  more  or  less  profuse  purulent  discharge  appears. 
Third  stage :  After  two  to  four  weeks  the  discharge  ceases  and  the  eye 
may  return  to  the  normal,  but  as  a  rule  the  thickening  of  the  con- 
junctiva and  so-called  papillary  swelling  continue  for  some  time.  The 
chief  danger  in  this  disease  is  from  ulceration  and  sloughing  of  the 
cornea.  The  chemosis  of  the  conjunctiva  strangulates  the  vessels  at 
the  margin  of  the  cornea,  shutting  off  its  nutrition  and  reducing  its 
vitality.  "When  infiltration  and  ulceration  begin,  the  tendency  is  to 
spread  and  perforate.  If  perforation  occur  the  eye  may  heal,  but  be 
blind  from  adherent  leucoma:  or  general  infection  and  panophthalmitis 
may  result  and  destroy  the  eye  entirely.  In  some  virulent  cases  in 
very  delicate  and  poorly  nourished  babies  the  cornea  seems  to  melt 
away. 

Treatment. — In  all  cases  where  an  infection  of  the  birth  canal  is 
suspected,  efforts  should  be  directed  to  cleansing  it  thoroughly  before 
the  membranes  have  ruptured  or  as  early  in  labor  as  possible.  As  soon 
as  the  head  is  born,  if  there  be  a  delay  in  the  delivery  of  the  shoulders, 
the  baby's  face  should  be  washed  with  boric  solution  and  immediately 
afterwards  the  eyes  filled  with  a  twenty-five  per  cent,  solution  of  argyrol, 
or  a  ten  per  cent,  solution  of  protargol.  A  two  per  cent,  solution  of 
nitrate  of  silver,  according  to  the  original  method  of  Crede,  is  less  used 
than  formerly.  If,  in  spite  of  these  precautions,  the  disease  develop,  a 
vigorous  campaign  should  be  commenced  at  once,  and  the  first  requisite 
is  a  trained  nurse.  The  eyes  should  be  gently  irrigated  during  the 
first  stage  every  three  hours  night  and  day  with  warm  boric  solution, 
using  an  ounce  or  two  for  each  eye  each  time,  the  lids  being  held  open 
as  well  as  possible  without  touching  the  conjunctiva  or  cornea.  After 
each  irrigation  a  drop  of  twenty-five  per  cent,  solution  of  argyrol  should 
be  instilled  into  the  eye  and  the  edges  of  the  lids  anointed  with  borated 
vaseline  to  prevent  agglutination  and  to  allow  constant  drainage.  As 
soon  as  pus  begins  to  flow  the  eyes  should  be  irrigated  every  hour  and 
the  argyrol  may  be  used  every  two  hours  and  more  freely.  If  the 
cornea  become  hazy  a  drop  of  one-half  per  cent,  solution  of  atropia 
sulphate  should  be  instilled  three  times  a  day,  after  a  hot  fomentation 
applied  by  saturating  pledgets  of  cotton  in  boric  solution  at  a  tem- 
perature of  120°  F.  (48.9°  C),  changing  the  compresses  every  minute 
for  fifteen  minutes.  As  the  discharge  of  pus  begins  to  diminish  it  will 
not  be  necessary  to  disturb  the  baby  so  often,  and  when  it  has  ceased 
altogether  the  case  should  be  managed  as  one  of  chronic  conjunctivitis. 
The  treatment  of  these  cases  has  been  very  much  simplified  by  the  dis- 
covery of  the  organic  salts  of  silver,  of  which  argyrol  unquestionably 
holds  first  place.  Protargol  is  as  effective  but  more  irritating,  and 
the  nitrate  of  silver,  which  for  a  century  was  facile  princeps,  but 
which  in  unskilled  hands  did  so  much  harm,  need  no  longer  be  considered. 
Iced  compresses  have  been  much  used  in  the  first  stage  of  this  disease,. 


PHLYCTENULAR    KKRATOCOXJ  i:\CTIVITIS  531 

but  cold  has  undoubtedly  a  depressing  effect  upon  the  nutrition  oi'  the 

cornea.     If  used  at  all   it  should  be  very  early,  and  only  in'the  case  ol* 
vigorous  babies  for  short  periods  of  time. 

Croupous  Conjunctivitis  is  an  inflammation  in  which  an  exudate 
forms  upon  but  does  not  infiltrate  the  conjunctiva.  Micro-organisms 
identical  with  those  found  in  diphtheritic  membrane  may  be  present,  but 
there  are  no  constitutional  symptoms  and  the  cornea  is  not  involved. 

The  symptoms  are  those  of  catarrhal  conjunctivitis.  The  membrane 
forms  on  the  palpebral  conjunctiva,  and  when  it  is  pulled  off  a  raw 
surface  is  exposed  upon  which  the  membrane  re-forms. 

Etiology.- — This  form  of  conjunctivitis  results  from  burns  with  lime, 
acids,  molten  metals,  and  nitrate  of  silver.  It  may  also  be  due  to 
infection. 

Treatment  is  that  of  acute  catarrhal  conjunctivitis.  Irritating  appli- 
cations must  be  avoided. 

Diphtheritic  Conjunctivitis. — The  Klebs-Loeffler  bacillus  may  cause 
a  variety  of  forms  of  conjunctivitis.  The  streptococcus  also  may  cause 
a  membranous  form  which  cannot  be  differentiated  clinically  from  so- 
called  true  diphtheritic  infection.  Diphtheritic  conjunctivitis  is  an 
acute  contagious  inflammation  due  to  the  Klebs-Loeffler  bacillus  and 
characterized  by  exudation  and  infiltration,  with  a  tendency  to  necrosis 
of  the  involved  tissues  and  profound  constitutional  depression.  The 
disease  affects  children, — is  rare  in  this  country,  but  common  in  North 
Germany. 

Symptoms. — The  lids  are  swollen,  red  and  tender.  The  conjunctiva 
is  covered  by  a  yellowish-gray  exudate  which  also  infiltrates  its  substance. 
The  exudate  disappears  at  the  end  of  a  week  and  is  followed  by  sup- 
puration ;  the  cornea  usually  ulcerates,  and  the  prognosis  for  sight  is 
always  grave. 

Treatment. — If  the  Klebs-Loeffler  bacillus  is  found,  antitoxin  should 
be  used  at  once,  and  in  any  case  the  general  strength  and  nutrition 
should  be  maintained.  Locally  the  treatment  should  be  similar  to  that 
described  for  purulent  ophthalmia. 

Phlyctenular  Keratoconjunctivitis  is  characterized  by  the  de- 
velopment of  phlyctenules  or  pimples  on  the  bulbar  conjunctiva  and 
cornea,  which  break  down  at  their  apices  and  form  ulcers. 

Symptoms. — The  phlycta?nules  are  small  elevations,  the  size  of  millet- 
seed,  surrounded  by  circumscribed  areas  of  redness.  They  often  occur 
in  crops  and  may  heal  without  ulcerating.  When  they  are  situated  on 
the  cornea  the  ulcer  is  usually  superficial  and  heals  without  much 
scarring,  but  may  spread  into  the  substance  of  the  cornea  and  even 
perforate.  There  is  usually  great  photophobia  and  blepharospasm  when 
the  cornea  is  involved,  and  always  considerable  laehrymation.  As  a 
result  of  the  tearing  there  is  frequently  blepharitis,  and  eczema  of  the 
lids  and  face.  Children  with  this  disease  avoid  the  light,  keep  the  head 
down,  the  eyes  closed,  and  seek  the  dark  corners.  Nasal  catarrh  and 
adenoids  are  usually  present  and  may  be  etiological  factors. 


532  DISEASES    OF    THE    EYE 

Etiology. — The  disease  may  affect  adults,  but  is  commonest  in  poorly 
nourished  children  of  the  lymphatic  type.  It  always  seems  to  depend 
upon  some  constitutional  error  even  though  it  occasionally  occurs  in  the 
children  of  the  well-to-do  who  are  apparently  in  good  health. 

Treatment. — Calomel  dusted  into  the  eye  daily  is  the  remedy  par 
excellence.  After  the  acute  symptoms  have  subsided  the  ointment  of 
yellow  oxide  of  mercury  helps  to  promote  the  absorption  of  infiltrates 
and  fresh  scars  of  the  cornea.  The  eyes  should  be  irrigated  three  or 
four  times  a  day  with  warm  boric  solution.  If  there  be  pain  and  photo- 
phobia, atropine  one-half  per  cent,  solution  should  be  instilled  after 
the  use  of  hot  fomentations  for  fifteen  minutes,  three  or  four  times  a 
day.  Bandages  should  not  be  applied.  If  fissures  occur  at  the  outer 
canthus  they  should  be  touched  with  two  per  cent,  solution  of  nitrate  of 
silver.  Appropriate  general  treatment  and  regulation  of  diet  are  neces- 
sary. Sweets,  pastry,  tea  and  coffee  should  be  interdicted.  Syrup  of 
the  iodide  of  iron  and  cod-liver  oil  are  often  helpful.  Fresh  air  and 
sunshine  are  very  necessary.  If  blepharospasm  be  not  relieved  by  the 
atropine,  holocaine  in  one  per  cent,  solution  may  be  tried  in  addition. 
Frequently  a  cold  douche  to  the  eyes  and  face  is  an  excellnt  measure. 

Injuries  of  the  Conjunctiva  comprise  contusions,  wounds,  and 
burns. 

Ecchymosis  of  the  conjunctiva  may  occur  from  blows  and  from  the 
rupture  of  a  small  vessel  during  a  severe  paroxysm  of  whooping-cough 
(Fig.  213) .  It  is  unimportant  and  will  disappear  in  a  few  days.  Absorp- 
tion may  be  hastened  by  hot  applications  and  massage. 

Burns  op  the  Conjunctiva  and  cornea  are  very  painful,  and  serious 
complications  are  apt  to  follow  their  healing.  If  union  between  the  lids 
and  globe  occur  the  condition  is  called  symblepharon. 

Treatment. — The  eye  should  be  thoroughly  flushed  with  boric  or  salt 
solution  as  soon  as  possible,  and  if  the  burn  be  due  to  lime,  acid,  or  other 
caustic,  it  should  be  neutralized  by  appropriate  means.  It  is  well  to 
remember  that  sugar  forms  an  insoluble  compound  with  lime,  and  syrup 
of  some  kind  is  always  at  hand.  Diluted  vinegar  will  neutralize  and 
dissolve  lime.  The  conjunctival  sac  should  then  be  filled  with  sterile 
vaseline  and  iced  compresses  applied,  as  already  described,  and  con- 
tinued for  twenty-four  hours  if  there  be  pain.  If  the  cornea  be  involved, 
atropine  should  be  used.  Irrigation  should  be  kept  up  every  three  or 
four  hours,  the  vaseline  used  each  time,  and  once  a  day  the  agglutinated 
surfaces  gently  separated  with  a  sterile  probe.  A  sharp  wooden  tooth- 
pick is  the  best  instrument  with  which  to  pick  grains  of  powder  from 
the  conjunctiva  and  cornea,  and  a  fine  stream  of  boric  solution  facilitates 
the  operation. 

"Wounds  op  the  Conjunctiva,  not  involving  the  deeper  structures 
of  the  eye  or  orbit,  heal  kindly  if  carefully  drawn  together  by  fine 
sutures  and  kept  clean. 

Interstitial  Keratitis  is  a  chronic  inflammation  of  the  cornea  char- 
acterized by  cellular  infiltration  of  its  middle  and  posterior  layers.     It 


WOUNDS    OF    THE    CONJUNCTIVA  533 

never  leads  to  ulceration,  but  is  accompanied  by  more  or  less  inflamma- 
tion of  the  iris  and  ciliary  body.  It  is  of  frequent  occurrence  in  child- 
hood, usually  beginning  between  the  fifth  and  fifteenth  years.  It  is  rarely 
seen  in  infancy,  though  congenital  cases  have  been  reported,  and  one  case 
was  seen  at  sixty  years. 

Symptoms. — The  infiltration  may  begin  at  the  centre  or  at  the 
periphery  of  the  cornea,  but  in  either  case  it  gradually  spreads 
until  the  entire  area  is  opaque  and  vision  is  sometimes  reduced  to  per- 
ception of  light.  At  this  period  deep-seated,  newly-formed  vessels  make 
their  appearance,  usually  in  circumscribed  sectors  of  the  cornea,  giving 
rise  to  a  yellowish-red  discoloration  known  as  the  salmon-patch.  This 
period  of  infiltration  and  vascularization  may  last  two  months  and  is 
accompanied  by  pain,  photophobia,  lachrymation,  and  poor  sight.  Both 
eyes  are  usually  affected.  After  the  infiltration  is  complete  the  inflam- 
mation begins  to  subside,  the  cornea  clears  up,  the  vessels  disappear, 
and  vision  improves.  Several  months  are  required  for  this  process,  and 
as  the  centre  or  pupillary  area  of  the  cornea  is  the  last  to  clear,  the 
vision  is  very  poor  for  a  long  time,  and  in  cases  which  do  not  receive 
proper  treatment  early,  the  eyes  may  be  rendered  practically  blind  by 
iridocyclitis,  chorioiditis,  and  permanent  opacities  of  the  cornea. 

Etiology. — More  than  fifty  per  cent,  of  the  cases  are  due  to  inherited 
syphilis, — practically  all  of  those  occurring  in  children.  The  disease  may 
be  due  to  trauma,  to  acquired  syphilis,  and  to  tuberculosis. 

Treatment. — Atropine  should  be  used  in  sufficient  dosage  to  relieve 
the  pain  and  keep  the  pupil  dilated.  Its  effect  is  increased  by  the  addi- 
tion of  cocaine  and  the  use  of  hot  fomentations.  Smoke-tinted  glasses 
should  be  worn  in  a  bright  light.  When  the  cornea  begins  to  clear 
absorption  may  be  hastened  by  massage  with  yellow  oxide  of  mercury 
ointment,  one  per  cent.  The  constitutional  treatment  must  be  suited  to 
the  condition  of  the  patient.  Good  nutrition  must  be  maintained. 
Calomel  in  small  doses,  iodonucleoid,  corrosive  sublimate,  syrup  of  the 
iodide  of  iron,  and  nutrient  tonics  are  appropriate  remedies. 

Iritis. — Inflammation  of  the  iris  may  occur  in  an  acute  form  in  the 
early  months  of  infancy  from  hereditary  syphilis,  and  the  more  chronic 
gummatous  variety  is  occasionally  seen  in  the  early  years  of  childhood. 
Tubercular  and  traumatic  iritis  may  also  occur  in  childhood. 

Symptoms. — The  disease  is  recognized  by  pericorneal  injection,  dis- 
coloration of  the  iris,  sluggish  or  fixed  pupil,  and  adhesions  between  the 
pupillary  margin  of  the  iris  and  the  lens  capsule.  The  adhesions  may 
not  be  apparent  until  a  drop  of  atropine  solution  is  instilled.  In  the 
gummatous  and  tubercular  varieties  there  is  in  addition  the  presence 
of  nodules  or  circumscribed  swellings  in  the  iris.  Pain  is  not  always 
present,  but  usually  is  severe,  neuralgic  in  character,  and  worse  at 
night.     There  is  always  photophobia  and  lachrymation. 

Treatment. — Hot  fomentations  should  be  used  every  three  hours 
while  the  pain  is  severe,  and  sufficient  atropine  to  keep  the  pupil  well 
dilated.     The  eyes  must  be  protected  from  the  light.     If  these  measures 


534  DISEASES    OF    THE    EYE 

do  not  relieve  the  pain,  leeching  of  the  temples  is  of  great  benefit.  Ap- 
priate  constitutional  treatment  must  be  employed. 

Cataract. — Children  are  sometimes  born  with  completely  developed 
cataract,  often  associated  with  other  defects  or  diseases  of  the  retina, 
optic  nerve,  or  chorioid.  Cataracts  of  various  forms  may  also  develop 
during  infancy  and  childhood.  Anterior  polar  cataract  is  due  to  per- 
foration of  a  corneal  ulcer  and  inflammatory  changes  in  the  anterior 
portion  of  the  lens  and  capsule. 

Symptoms. — Diagnosis  is  readily  made  from  the  gray  pupil  and 
evident  inability  to  see. 

Treatment. — Congenital  cataract  should  be  operated  upon  by  the 
method  of  discission  during  the  second  year  of  life,  if  possible.  In  central 
and  pyramidal  cataract,  if  there  be  sufficient  clear  lens  available,  an 
iridectomy  may  serve  better  than  removal  of  the  lens. 

Injuries  of  the  Eye,  with  perforation  of  the  globe,  are  very  common 
in  children.  Such  injuries  are  always  serious,  often  resulting  in  the 
loss  of  the  injured  eye  by  infection,  and  the  sound  one  by  sympathetic 
inflammation. 

Symptoms  of  perforation  are  the  presence  of  a  wound,  reduced 
vision,  possibly  blood  in  the  anterior  chamber,  and  loss  of  the  normal 
tension. 

Treatment. — Atropine  should  be  used  as  soon  as  the  eye  has  been 
cleansed,  and  dilatation  of  the  pupil  secured  and  maintained  if  possible. 
Iced  compresses  do  much  good  in  the  first  day  or  two,  while  asepsis  must 
be  observed  if  the  eye  is  to  be  saved.  If  an  eye  become  sightless  after 
such  an  injury,  especially  if  it  is  shrunken  or  tender,  it  is  a  source  of 
danger  to  the  fellow-eye  and  should  be  removed. 

Refraction  of  the  Eye  in  Childhood. — Myopia  almost  never  oc- 
curs in  infancy,  but  is  an  acquired  defect  manifesting  itself  during 
school  life.  If  not  properly  managed  it  may  continue  to  increase  and 
even  result  in  blindness.  Hyperopia,  so-called  far-sightedness,  is  the 
usual  condition  in  infancy  and  childhood,  and  astigmatism  of  measurable 
degree  is  found  in  perhaps  ninety  per  cent,  of  all  eyes.  The  great  fre- 
quency of  errors  of  refraction  in  school  children  is  responsible  for  many 
of  the  inflammatory  conditions,  and  at  least  fifty  per  cent,  of  head- 
aches are  due  to  eye-strain.  Many  a  backward  child  is  so  because  of  the 
difficulty  he  experiences  in  eye-work,  and  the  constant  strain  upon  the 
nervous  system  is  no  doubt  the  cause  of  much  general  nervousness,  irri- 
tability, and  poor  health.  In  all  such  cases  the  eyes  should  be  examined 
under  the  influence  of  a  mydriatic,  as  no  accurate  measurements  for 
glasses  can  otherwise  be  made.  If  glasses  are  prescribed  early,  when 
they  are  really  needed,  the  eyes  of  the  children  often  develop  more  com- 
pletely and  become  so  much  stronger  that  the  lenses  may  after  a  time 
be  discarded. 

Paralysis  of  one  or  more  of  the  extra-ocular  muscles  may  occur  after 
diphtheria,  meningitis,  and  other  diseases.  If  complete,  the  deviation  of 
eye  is  easily  seen,  and  if  the  patient  be  old  enough  diplopia  will  be  com- 


STRABISMUS— N  YST  AGMUS  535 

plained  of.  It  will  also  be  noticed  that  when  the  fixing  eye  is  covered  the 
patient  cannot  turn  the  other  eye  in  the  direction  of  the  paralyzed 
muscle.  Prognosis  and  treatment  depend  upon  the  cause.  Paralysis  of 
accommodation,  with  or  without  paralysis  of  one  or  more  of  the  extra- 
ocular muscles,  is  not  infrequent  after  diphtheria.  It  is  manifested  by 
inability  to  see  near  things.  Recovery  is  usually  complete,  but  rest  and 
strychnia  are  indicated.  Congenital  absence  of  one  or  more  of  the  eye 
muscles  has  been  noted. 

Strabismus,  or  Squint,  is  a  faulty  co-ordination  of  the  movement  of 
the  two  eyes.  The  excursions  of  both  eyes  are  normal  in  all  directions, 
but  there  is  a  deviation  of  the  visual  line  of  one  eye,  the  same  faulty 
relationship  of  the  axes  being  maintained  in  every  direction  in  which 
the  eyes  are  turned.  This  fact  distinguishes  the  condition  from  paralysis 
and  gives  rise  to  the  term  concomitant.  Convergent,  concomitant  stra- 
bismus is  the  commonest  form.  It  may  be  occasional  or  constant, 
monocular  or  alternating.  There  is  no  diplopia  except  in  the  very  begin- 
ning, the  image  in  the  squinting  eye  being  quickly  suppressed.  There 
is  usually  diminished  acuteness  of  vision  in  the  squinting  eye,  but  this 
may  be  a  cause  or  a  consequence  of  the  squint. 

Etiology. — Congenitally  defective  vision  in  one  eye  lessens  the  nor- 
mal desire  for  binocular  vision;  errors  of  refraction  disturb  the  rela- 
tion between  accommodation  and  convergence,  and  make  co-ordination 
more  difficult ;  and  acquired  defects  interfere  with  the  vision  of  one 
eye.  Strabismus  may  be  precipitated  by  any  exhausting  illness  and 
may  follow  a  true  paralysis  of  one  muscle  in  which  contraction  of  the 
antagonist  occurs  before  the  paralyzed  muscle  fully  regains  its  power. 
Squint  usually  develops  between  the  second  and  fourth  years  of  life,  when 
the  child  is  beginning  to  use  the  eyes  more  for  near  seeing. 

Treatment  consists  in  the  improvement  of  the  vision  of  the  defective 
eye  by  the  use  of  the  blinder  over  the  better  eye  some  hours  every  day ; 
the  accurate  correction  of  errors  of  refraction  under  atropine,  and 
perhaps  the  prolonged  use  of  the  mydriatic ;  stereoscopic  and  other 
exercises  to  develop  binocular  vision,  and  finally  operation,  if  necessary. 
All  cases  should  be  brought  under  treatment  as  early  as  possible  to  secure 
favorable  results. 

Nystagmus  is  a  more  or  less  rhythmic  involuntary  oscillation  of  the 
eyeballs,  vertical,  lateral,  or  rotary,  sometimes  due  in  children  to  imper- 
fect sight  in  both  eyes.  The  involuntary  movements  do  not  interfere  with 
the  voluntary  movements  of  the  eye,  but  accompany  them.  Nystagmus 
and  squint  are  frequently  associated.  The  oscillations  are  increased  by 
fatigue  or  excitement.  If  the  sight  can  be  improved  by  glasses,  the  dis- 
tressing symptoms  "are  often  much  relieved  and  some  cases  have  been 
benefited  by  operations  for  the  associated  squint. 

Exophthalmos  is  seen  at  all  ages.  It  occurs  in  infancy  as  a  result 
of  hemorrhages  into  the  orbit  usually  associated  with  scorbutus.  Promi- 
nence of  the  eyeball  with  thyroid  enlargement,  with  or  without  tachy- 
cardia, is  occasionally  seen  in  young  children. 


536  DISEASES    OF    THE    EAR 


DISEASES   OF  THE  EAR 

IMPORTANCE    OF    OTITIS   MEDIA 

The  results  of  two  converging  lines  of  observation  have  in  recent 
years  emphasized  the  importance  of  disorders  of  the  ear  in  infancy  and 
childhood.  First,  clinically,  it  is  becoming  more  apparent  that  otitis 
media  is  a  common  complication  of  catarrhal  and  adenoid  disorders  of 
the  nasopharyngeal  tract,  as  well  as  a  frequent  sequel  to  the  more  acute 
infections,  as  diphtheria,  measles,  scarlet  fever,  and  influenza.  Second, 
accumulating  data  from  careful  post-mortem  findings  show  an  astonish- 
ing percentage  of  suppurative,  ulcerative,  and  necrotic  processes  of  the 
middle  ear  and  adjacent  structures.  No  age  of  childhood  is  exempt. 
Infants  are  born  with  pus-engorged  tympanic  cavities,  so  that  there  is 
evidence  that  the  pyogenic  infection  developed  in  utero. 

The  seriousness  of  tympanic  suppuration  becomes  apparent  when  the 
anatomical  relationship  of  this  cavity  in  infancy  is  recalled  (page  21). 
Not  only  the  embryonal  structure,  but  the  functional  role  of  the 
aural  mechanism,  brings  the  consideration  of  its  disorders  into  three 
distinct  fields.  The  external  ear,  including  its  meatus,  canal,  and 
outer  drum  surface,  as  a  portion  of  the  integument  is  susceptible  to 
skin  disorders,  modified  by  its  relations  to  other  structures.  Eczema, 
impetigo,  furunculosis,  erysipelas,  congenital  deformities,  traumatisms, 
foreign  bodies  in  canal,  and  impaction  of  cerumen  are  among  the  com- 
monest outer  ear  diseases,  affecting  the  function,  of  hearing  only  as  they 
interfere  mechanically  with  the  conduction  of  sound;  or,  secondarily, 
by  extension  of  inflammatory  processes  to  the  adjacent  deep  aural 
structures. 

Foreign  bodies  in  the  external  meatus  should  be  referred  immediately 
to  the  physician,  as  awkward  attempts  at  removal  by  the  unskilled  are 
frequently  productive  of  mischief.  In  the  majority  of  cases  forcible 
syringing  with  a  warm,  bland  aseptic  liquid  should  precede  instrumental 
attempts,  which  are  rendered  thereby  usually  unnecessary. 

Discharge  from  the  ear  is  sometimes  due  to  furuncles  of  the  meatus 
which,  in  common  with  eczema  and  impetigo,  are  discussed  under  Skin 
Lesions. 

The  middle  ear,  including  the  tympanic  cavity,  ossicles,  with  mastoid 
antrum,  and  Eustachian  tube,  are,  histologically,  part  of  the  upper  air 
passages,  and  its  normal  function  is  largely  dependent  on  its  free  connec- 
tion with  the  same.  Occlusion  of  the  Eustachian  tube,  even  temporarily, 
interferes  with  hearing,  while  its  permanent  closure  invariably  leads 
not  only  to  deafness  but  to  a  train  of  pathologic  conditions  from  in- 
terference with  ventilation  of  the  tympanum.  Equable  air  pressure, 
secured  through  a  patulous  Eustachian  tube,  is  not  only  necessary 
to  tension  and  vibration  of  the  drum  membrane  but  is  essential  to 
the  normal  circulation  of  the  blood  and  lymph  channels  of  the  tym- 
panic  mucosa.      Diminished   intra-aural   pressure   means    engorgement 


MIDDLE-EAR    INFLAMMATION  537 

of  both  blood  and  lymph  vessels,  with  increased  catarrhal  secretions  and 
diminished  lymph  drainage. 

Without  frequent  renewal  of  tympanic  air,  the  replacement  of  the 
absorbed  oxygen  by  the  inferior  bulk  of  carbonic  acid  gas  results  in 
rarefication. 

To  this  morbid  train  only  pyogenic  infection  is  necessary  to  light 
up  one  of  the  commonest  disorders  of  infancy, — viz.,  suppurative  otitis 
media.  Staphylo-,  strepto-,  and  pneumococci,  the  influenza,  diphtheria, 
tubercle  and  colon  bacilli,  and  even  the  gonococcus,  find  their  way  to 
this  tract  in  about  the  order  of  frequency  named.  The  history  of  the 
subsequent  infection  and  the  involvement  of  adjacent  tracts,  as  in  the 
development  of  cerebral  or  cerebellar  abscess,  lepto-  or  pachymeningitis, 
thrombosis  or  phlebitis  of  the  sinuses,  bone  necrosis,  and  subperiosteal 
accumulations  of  pus,  depends  partly  on  the  nature  of  the  infection, 
whether  simple  or  mixed,  and  partly  upon  the  facility  for  extension 
from  the  tympanum  furnished  by  the  patulous  squamo-petrosal  and  the 
squamo-mastoid  sutures,  the  many  communicating  veins  and  the  sheaths 
of  the  nerves  which  pass  through  the  petrosal  foramina. 

To  the  list  of  exciting  causes  of  middle  ear  inflammation  may  be 
added  traumatism  from  external  violence,  as  puncture  or  incision  of 
drum  membrane,  rupture  from  concussion  or  blows  on  head  or  ear,  sea- 
bathing, and  long  exposure  to  cold  drafts.  Vomited  matter  and  even 
worms  have  found  their  way  to  the  ear  through  the  Eustachian  tube. 

The  diagnosis  of  acute  middle  ear  inflammation  is  not  always  readily 
made.  Where  suppuration  is  abundant  pressure  symptoms,  such  as 
excruciating  otalgia,  an  uncomfortable  feeling  of  fulness  on  the  affected 
side,  impaired  hearing,  ringing  or  roaring  sounds  in  the  ear,  moderate 
or  severe  headache,  persistent  cough  without  other  explanation,  and 
various  obstinate  nervous  symptoms,  point  to  the  seat  of  trouble.  There 
are  the  following  symptoms:  a  sudden  rise  of  temperature  from  two 
to  five  degrees,  with  or  without  history  of  a  chill  or  convulsion,  sometimes 
vomiting,  usually  anorexia,  and  furred  tongue.  If  an  infant,  there  may 
be  crying  and  sleeplessness.  The  cry  is  sharp  and  piercing,  with  occa- 
sional rolling,  and  (in  older  infants)  beating  of  the  head  with  the  hands. 
Examination  reveals  tenderness  on  pressure  over  the  tragus  and  usually 
over  the  styloid  and  mastoid  processes,  and  the  drum  membrane  presents 
a  convexity  which  sometimes  appears  reddened.  Without  interference 
these  symptoms  will  continue  from  three  to  five  days,  or  until  relief  is 
afforded  by  spontaneous  rupture  of  the  membrane  and  free  discharge  of 
pus.  After  subsidence  of  the  acute  symptoms,  the  ear  may  discharge 
pus  continuously  or  intermittently  for  days  or  even  weeks.  One  or  both 
ears  may  be  involved.  Double  otitis  is  most  frequently  seen  compli- 
cating or  following  the  infectious  diseases  characterized  by  anginas. 
Scarlet  fever  furnishes  the  greatest  number  of  double  lesions,  usually  as 
sequela?,  and  they  are  especially  obstinate  and  destructive  after  this 
exanthem.  Otitis,  complicating  an  acute  disorder — as  pneumonia,  enter- 
itis, typhoid  fever — is  frequently  marked  at  its  onset  by  symptoms  of 


538  DISEASES    OF    THE    EAR 

the  prevailing  disorder.  Occasionally,  meningitis  is  suspected,  until  a 
purulent  discharge  from  the  auditory  meatus  reveals  the  cause  of  the 
supposed  cerebroid  symptoms.  Many  cases  which  occur  alone,  or  as 
complications  or  sequelae  to  other  disorders,  continue  discharging  at 
intervals  after  recovery  from  the  acute  attack.  So  that  the  running  ear 
marks  every  fresh  exposure  to  cold  during  months  and  even  years  of 
childhood,  thus  constituting  a  chronic  or  recurrent  form  of  suppurative 
otitis  media. 

Although  a  common  disorder  most  prevalent  among  children  of 
malhygienic  environment,  the  prognosis  is  always  uncertain.  The  long- 
continued  pressure  of  suppurative  processes  in  close  relation  to  im- 
portant structures  is  a  prolific  cause  of  the  grave  cerebral  disorders  of 
infancy  and  early  childhood.  The  permanent  impairment  of  hearing 
from  destruction  of  the  drum  by  necrosis,  or  ankylosis  of  the  ossicles  or 
other  structural  changes  in  the  auditory  apparatus,  is  not  nearly  so 
common  as  one  would  be  led  to  suppose. 

The  prophylaxis  of  otitis  media  should  begin  with  care  of  the  nose 
and  throat,  as  in  the  large  majority  of  cases  the  tympanum  is  probably 
infected  through  the  Eustachian  tube.  During  all  the  infectious  diseases 
of  childhood  the  ear  should  be  frequently  examined  as  to  the  condition 
of  the  drum  membrane.  If  this  is  found  bulging  it  is,  even  in  the  absence 
of  other  symptoms,  an  indication  of  pressure  from  within,  probably  from 
pus.  This  pressure  is  sometimes  due  to  hemorrhage  into  the  tympanum, 
occasionally  seen  in  cerebrospinal  meningitis,  scorbutus,  leukaemia, 
Hodgkin's  disease,  pernicious  anaemia,  haemophilia,  and  purpura. 

Treatment. — The  presence  of  pus  calls  for  its  evacuation,  best  accom- 
plished by  a  semicircular  incision  of  the  membrane,  parallel  with  and 
near  to  the  lower  anterior  border.  This  location  avoids  the  ossicles  and 
secures  better  drainage.  A  bulging  confined  to  the  upper  posterior  quad- 
rant is  indicative  of  attic  suppuration,  and  may  best  be  drained  bj^  punc- 
ture of  Schrapnell's  membrane.  Discharge,  if  tardy  on  account  of 
viscidity,  may  be  promoted  by  irrigation  of  the  external  meatus  with  hot 
boric  solutions.  A  pledget  of  absorbent  cotton  should  be  left  in  the 
meatus  to  act  as  a  wick.  The  same  treatment  is  applicable  to  spon- 
taneous perforation  of  the  drum  membrane  which  is  occasionally  the 
first  evidence  of  otitis.  Intense  otalgia,  without  drum  convexity,  may 
or  may  not  indicate  beginning  suppurative  otitis.  The  pain  may  be 
relieved  by  hot  applications,  dry  or  moist.  The  former  are  made  by 
means  of  the  bag  of  hot  water  or  salt,  the  Japanese  hot-box,  or  an 
electric  heater  applied  over  the  auricle.  The  second  method  consists  of 
filling  the  external  meatus  with  hot  sterile  water,  being  especially  careful 
to  dry  out  with  warm  absorbent  cotton.  This  process  may  be  repeated 
frequently. 

The  macerating  effect  of  poultices  and  extensive  fomentations  is  con- 
sidered sufficient  reason  for  condemnation.  At  the  onset  of  acute  otitis, 
general  and  local  depletion  is  indicated,  as  some  of  the  symptoms,  espe- 
cially pain,  may  be  due  largely  to  accompanying  congestion.     Hence, 


SUPPURATIVE    OTITIS    MEDIA  539 

free  purgation,  heat  to  the  extremities,  and  occasionally  rubefacients 
and  even  leeches  behind  the  auricle,  are  in  order.  Symptoms  have  dis- 
appeared and  apparent  abortion  of  the  inflammatory  process  has  followed 

this  treatment.  Persistent  or  frequently  recurrent  discharge  from  the 
tympanum,  covering  a  period  of  several  weeks,  is  considered  by  many 
good  authorities  as  evidence  of  mastoid  involvement.  Persistent  cases 
should  always  be  referred  to  the  aural  surgeon. 

Neglected  suppurative  otitis  media,  in  the  majority  of  cases,  sooner 
or  later  develops  mastoiditis.  When  the  intimate  relation  of  the  mastoid 
antrum  to  the  tympanum  is  recalled,  both  cavities  and  the  connecting 
aditus  having  a  common  mucous  lining,  its  frequency  as  a  sequel  is  not 
surprising.  On  the  contrary,  the  wonder  is  that  any  continued  middle 
ear  suppuration  fails  to  invade  this  easy  route  of  extension.  That 
many  such  lesions  of  the  mastoid  antrum,  and  even  cells,  when  they  exist, 
go  undiagnosed  with  ultimate  recovery,  is  undoubtedly  true.  Still  the 
condition  must  remain  a  perpetual  menace  to  life  through  necrosis  of 
the  intervening  bony  tissue  and  invasion  of  adjacent  structures.  Not 
infrequently  acute  mastoiditis  follows  hard  upon  acute  suppuration  of 
the  tympanum  with  or  without  marked  middle-ear  symptoms.  There 
is  then  a  sudden  rise  of  temperature,  throbbing  pain,  remittent  tin- 
nitus, in  infants  convulsions,  somnolence  or  coma,  tenderness  over  the 
postauricular  region,  occasionally  boggy  tumefaction  and  redness  over 
the  mastoid,  with  outstanding  auricle,  coated  tongue,  and  constipation, 
writh  leucocytosis. 

On  the  other  hand  the  symptoms  of  suppuration  may  be  obscure  and 
resemble  atypical  typhoid,  influenza,  or  malaria,  in  which  the  absence 
of  plasmodia  and  presence  of  leucocytosis  point  to  pus  formation.  In- 
spection of  the  ear  may  show  bulging  of  the  membrane.  Paracentesis 
yields  but  a  little  viscid  pus,  followed  by  an  improvement  of  the  symp- 
toms or  even  apparent  recovery.  Days  or  even  weeks  later,  a  sudden 
attack  of  vertigo  or  coma  may  call  attention  to  the  forgotten  aural 
discharge.  An  operation  upon  the  mastoid  may  show  the  antrum  and 
cells  filled  with  purulent  material  and  granular  detritus  from  necrosis 
of  both  soft  and  hard  tissues  with  sequestra.  The  destruction  of  the  thin 
bony  walls  may  have  laid  bare  the  lateral  sinus  or  dura  mater,  exposing 
subdural  collections  of  pus.  The  pus  may  find  exit  through  the  masto- 
squamosal  suture,  not  infrequently  patulous  in  later  childhood,  and 
appear  under  the  periosteum,  back  of  the  ear,  as  a  superficial  abscess. 
It  may  erode  through  the  thin  bony  wall  into  the  external  meatus,  filling 
that  channel  with  its  tumefaction.  An  incision  in  either  position  will 
relieve  the  local  pain,  but  is  misleading  in  its  effects  since  it  delays  the 
more  urgent  radical  operation. 

From  the  foregoing  it  is  not  difficult  to  see  how  complications  and 
sequela?  from  neglected  purulent  otitis  and  mastoiditis  should  arise, 
such  as  phlebitis,  thrombosis  of  adjacent  veins  and  sinuses,  cerebral 
abscess,  meningitis,  internal  ear  involvement,  and  facial  paralysis  from 
pressure  on  the  seventh  nerve. 


540  DISEASES    OF    THE    EAR 

EAE    TUMORS. 

Of  the  tympanic  and  mastoid  neoplasms,  tubercles  are  undoubtedly 
the  most  common,  although  rarely  of  primary  occurrence.  It  may  occa- 
sion symptoms  of  subacute  suppurative  disease  of  these  cavities  and  is 
usually  associated  with  tuberculous  meningitis.  That  brain  abscesses  so 
seldom  follow  this  invasion  may  be  explained  by  the  rapid  fatal  termi- 
nation of  the  basilar  meningitis. 

The  subsequent  history  of  these  cases  makes  the  prognosis  extremely 
grave,  yet  recoveries  have  been  reported  after  extensive  destruction  of 
the  mastoid  bone  from  tubercular  processes. 

Cholesteatoma  is  occasionally  found  in  the  antrum  as  a  benign  though 
most  persistent  neoplasm,  reappearing  after  repeated  operations  for 
removal.  Sarcoma  of  this  location  is  not  extremely  rare  even  in  early 
infancy,  against  the  malignancy  of  which  all  operations  are  futile. 

INTERNAL    EAR. 

Otitis  interna  is  rare  in  infancy  and  childhood  and  is  seldom  a 
primary  disorder.  Its  commonest  form,  labyrinthitis,  is  generally  due 
to  pneumococcic  infection,  cerebrospinal  meningitis,  mumps,  and  ade- 
noids of  the  pharyngeal  wall.  Infection  from  the  middle  ear  occa- 
sionally invades  the  vestibule,  although  the  infrequency  of  the  infection 
by  this  route  is  a  matter  of  surprise.  The  want  of  articulations  and 
brittleness  in  the  petrous  bones  of  children  render  them  less  liable  to 
fractures  and  hemorrhages  with  resulting  injury  to  the  auditory  nerves. 
Although  rare,  the  possibility  of  labyrinthitis  should  be  kept  in  mind 
in  prolonged  obstinate  vomiting,  with  or  without  occipital  headache,  not 
explained  by  other  causes.  Chronic  nephritis,  diabetes,  and  congenital 
syphilis  are  occasionally  responsible  for  internal  disease  and,  as  in  later 
life,  cause  symptoms  of  vertigo,  nausea,  sudden  and  usually  permanent 
deafness  and,  in  older  children,  tinnitus  and  staggering  gait.  Pressure 
upon  the  auditory  nerve  from  hemorrhages,  serous  exudates,  tumors, 
sequestra?,  or  from  atrophy,  may  produce  symptoms  of  labyrinthine 
disease. 

In  double  labyrinthine  disease  the  suddenly  suspended  hearing  is 
seldom  restored.  In  patients  under  five  years  of  age  this  deafness 
usually  results  in  mutism.  The  importance  of  preserving  the  memory 
of  language  already  acquired  cannot  be  overemphasized. 


CHAPTER    XIV 

THE    SPECIFIC    INFECTIOUS    DISEASES 

EXANTHEMATA 

SCARLET    FEVER — SCARLATINA 

Scarlet  fever  is  an  acute,  contagious,  self-limiting  disease.  It  pre- 
sents four  fairly  constant  and  well-defined  symptoms, — viz.,  sore  throat, 
high  temperature,  characteristic  rash,  and  desquamation.  It  may  occur 
sporadically,  but  its  most  familiar  appearance  is  in  the  form  of  recur- 
ring epidemics  after  intervals  of  comparative  exemption  in  the  com- 
munity. In  large  cities  the  disease  is,  to  a  certain  extent,  endemic.  The 
severity  of  the  disease  does  not  appear  to  depend  upon  the  extent  of  the 
epidemic,  although,  as  in  many  other  diseases  mitigation  of  symptoms 
occurs  in  the  decadence.  Mild  symptoms  in  a  given  case  are  no  assur- 
ance that  the  next  victim  in  order  of  transmission  will  not  develop  a 
severe  type  of  the  disease.  The  reverse  is  also  true.  In  scarlatina  there 
is  a  noticeable  lack  of  the  universal  susceptibility  which  children  show 
in  the  other  specific  contagious  diseases.  Probably  little  more  than  fifty 
per  cent,  of  all  who  are  exposed  contract  the  disease  in  recognizable  form. 

Etiology. — On  account  of  the  gravity  and  wide  prevalence  of  scarlet 
fever  a  great  amount  of  research  and  much  discussion  have  been  devoted 
to  the  etiology,  thus  far  with  disappointing  results.  Although  no  organ- 
ism or  toxin  out  of  the  many  which  have  been  subjected  to  rigid  scrutiny 
has  fulfilled  all  the  requirements  of  a  specific  agent,  the  attention  of  bac- 
teriologists constantly  recurs  to  the  streptococcus,  both  on  account  of  its 
constant  presence  and  because  of  its  behavior  in  the  graver  forms  of  this 
disease.  While  normally  present  with  other  flora  of  the  mouth  in  health, 
in  the  angina  of  scarlet  fever  this  organism  more  than  any  other  shows 
evidence  of  great  activity  and  rapid  multiplication.  Its  presence  in 
the  blood  is  occasionally  demonstrated  even  in  mild  forms,  but  it  is  seen 
most  frequently  in  fatal  cases,  and  always  in  large  numbers  after  death 
from  this  disease.  In  fact,  many  have  claimed  that  whatever  be  the 
specific  cause  of  the  infection,  in  all  probability  the  fatal  termination  is 
due  to  streptococcremia. 

Symbiotic  activity  of  the  streptococcus  with  some  unknown,  perhaps 
ultra-microscopic,  organism  appears  to  many  a  reasonable  hypothesis 
for  the  phenomena.  Among  the  later  claimants  for  etiologie  recognition 
in  scarlatina  are  the  diplococcus  of  Class  and  the  protozoon  of  Mallory. 
In  regard  to  the  former,  several  bacteriologists  have  been  unable  to  con- 
firm the  findings  of  Class,  while  Mallory 's  organism  is  too  recently 
announced  to  have  allowed  time  for  demonstration. 

541 


542  THE    SPECIFIC    INFECTIOUS    DISEASES 

No  age  is  exempt  from,  scarlet  fever,  although  its  occurrence  in 
typical  form  in  adult  life  is  sufficiently  rare  to  attract  attention.  Its 
infrequency  in  early  infancy  is  a  matter  of  common  observation.  Cases 
are  reported,  however,  of  scarlatina  in  new-born  infants  whose  mothers 
were  suffering  from  the  disease.  There  are  also  records  in  which  healthy 
infants  have  been  born  of  mothers  who  were  passing  through  an  attack 
of  scarlet  fever.  The  susceptibility  to  scarlatina  increases  steadily  from 
the  end  of  the  first  to  the  fifth  year,  after  which  it  progressively  dimin- 
ishes. During  this  period  all  children  are  not  equally  susceptible,  as 
the  histories  of  epidemics  show  a  selection  of  individuals  exposed  to  the 
contagion  even  in  the  same  family.  This  presupposes  some  unknown 
receptivity.  That  this  apparent  immunity  to  the  scarlatinal  infection 
varies  in  the  same  individual  is  also  well  known.  Children  who  escape 
from  one  exposure  may  yield  to  a  later,  under  conditions  which  suggest 
even  diminished  virulency  of  infection.  Instances  are  not  wanting  in 
which  life  immunity  seemed  possessed  by  the  individual  who  passes 
unscathed  through  many  epidemics. 

Season  has  apparently  some  influence  upon  the  occurrence  of  scarlet 
fever,  the  early  winter  months  showing  not  only  the  greatest  number 
but  the  highest  mortality.  Several  explanations  have  been  offered,  among 
which  three  are  somewhat  generally  accepted:  first,  the  aggregation  of 
susceptibles  in  schools  which  reopen  in  September ;  second,  the  confine- 
ment to  the  house  in  the  winter ;  third,  the  unpacking  of  winter  clothing 
which  has  been  stored  in  dark  closets  and  drawers  during  the  summer, 
with  the  consequent  release  of  bacteria  the  vitality  of  which,  under 
favorable  conditions  of  darkness  and  dryness,  has  been  proven  to  be  very 
tenacious.  There  are  many  instances  which  go  to  show  a  remarkable 
vitality,  frequently  covering  a  period  of  several  years,  of  the  infecting 
agent  of  scarlet  fever  when  protected  from  the  action  of  sunlight  and 
fresh  air. 

The  common  source  of  infection  is  the  scarlet  fever  patient,  from 
whose  personal  emanations  (nasal  and  oral  secretions,  sputum,  urine, 
faeces,  sweat,  dermal  exfoliation,  and  possibly  breath)  the  poison  may 
extend  to  the  susceptible  child.  Most  frequently  this  occurs  by  direct 
contact,  but  the  poison  may  be  conveyed  by  clothing,  books,  letters, 
toys,  domestic  pets,  flies,  and  through  food  and  drink,  even  to  great 
distances.  A  common  carrier,  as  has  been  demonstrated  in  numerous 
epidemics,  is  milk,  which  forms  a  favorable  culture  medium  for  the 
scarlet-fever  poison,  and  may  introduce  it  in  active,  virulent  form  into 
many  homes. 

The  desquamative  stage  of  the  disease  was  formerly  regarded  as  the 
one  most  favorable  for  dissemination,  which  occurred  through  the  par- 
ticles of  exfoliated  epithelium,  in  which  form  the  poison  was  readily 
transmissible  through  any  medium,  and  might  be  air-borne.  Indubitable 
instances,  however,  have  shown  that  transmission  by  direct  contact  with 
a  patient  may  occur  at  any  stage  of  the  disease,  even  including  the 
period  of  incubation.     In  this  connection  attention  should  be  called  to 


SCARLET    FEVER  543 

a  source  of  infection  from  the  prevailing  sore  throat  so  commonly  seen 
during  epidemics  of  scarlet  fever.  This  is  justly  considered  a  masked 
form  of  scarlatinal  infection. 

The  mode  of  entrance  to  the  body  of  scarlet  fever  contagion  is  not 
positively  known.  The  infection  from  milk  would  suggcsl  the  probable 
absorption  from  the  digestive  tract,  while  many  circumstances  go  to 
show  that  the  mucosa  of  the  upper  respiratory  tract  offers  ready  access 
to  the  invading  germ.  As  in  other  infections  the  tonsils  and  absorbent 
tissue  of  the  adenoid  ring  probably  afford  a  gateway  for  the  scarlatinal 
organism  or  its  toxins.  This  is  emphasized  by  the  anginal  disturbance 
which  is  a  common  feature  of  this  disease.  Inoculation  experiments  have 
shown  that  the  abraded  skin  may  absorb  the  poison,  and  the  familiar 
puerperal  intoxication  from  scarlatinal  infection  shows  the  susceptibility 
of  the  blood  to  this  agent  by  whatever  route  introduced.  The  period  of 
incubation  varies  widely — in  exceptional  cases  from  one  day  to  three 
weeks — but  in  the  United  States  the  very  large  majority  develop  char- 
acteristic symptoms  in  less  than  a  week  after  exposure. 

Symptoms. — No  picture  of  scarlatina  can  be  presented  to  the  student 
that  may  not  be  misleading,  so  wide  are  the  variations  from  the  type  in 
this  disease.  A  typical  attack,  and  this  may  represent  a  third  of  the  cases 
as  met  in  general  practice,  develops  abruptly,  usually  after  a  few  hours 
of  malaise,  with  vomiting — which  may  be  repeated,  but  rarely  occurs 
after  the  first  day — chill  or  chilliness,  high  temperature  (103°-104°  F., 
39.5°-40°  C),  full  and  rapid  pulse  (120  to  160),  headache,  possibly 
delirium,  or  even  convulsions,  in  young  infants.  Examination  shows  a 
grayish-yellow  coating  of  the  tongue  through  which  the  swollen,  fungi- 
form papilla?  appear  as  bright  red  dots.  The  throat  is  hyperaemie,  the 
tonsils  are  often  enlarged,  and  the  glands  under  the  angle  of  the  jaw  are 
swollen  and  tender.  By  the  second  day  the  rash  appears,  usually  in  the 
clavicular  region  or  along  the  side  of  the  neck,  behind  the  ear,  whence  it 
spreads  around  the  neck  and  downwards  over  the  trunk,  involving  suc- 
cessively the  upper  and  lower  extremities.  In  twenty-four  hours  from  its 
first  appearance  the  exanthem  usually  covers  the  entire  body,  with  the 
exception  of  portions  of  the  face, — as  the  prolabia,  nose  and  chin.  The 
pallor  of  these  latter  present  a  vivid  contrast  to  the  surrounding  redness. 
The  rash  is  characteristic  and  has  been  variously  described  as  punctate 
and  uniformly  hypera?mic.  Strictly  speaking,  it  is  composed  of  fine, 
bright  red  points,  in  diameter  less  than  the  head  of  a  small  pin.  These 
are  distributed  evenly,  are  slightly  elevated  and  show  hyperasmic  areolae 
which  merge  into  those  of  adjacent  puncta.  As  the  exanthem  develops 
it  presents  the  appearance,  at  a  short  distance,  of  bright,  uniform  red- 
ness, which  fades  under  the  pressure  of  the  finger  but  quickly  resumes 
its  color  as  the  capillaries  refill.  Close  inspection,  especially  with  a  low 
magnifier,  will  show  the  points  of  deeper  scarlet  appearing  through  the 
hyperasmic  surface,  which  by  this  time  has  swollen  to  their  level.  Coin- 
cident with  the  development  of  the  exanthem  the  temperature  rises  to 
104°  or  105°  F.  (40°-40.5°  C.)  with  increase  in  pulse  and  respiration. 


544  THE    SPECIFIC    INFECTIOUS    DISEASES 

The  faucial  inflammation  increases  in  intensity  and  the  nasal  discharge, 
which  has  been  slight  in  the  beginning,  increases  perceptibly  and  may, 
with  extreme  throat  involvement,  become  mucopurulent.  The  throat 
may  be  so  swollen  and  painful  as  to  make  deglutition  difficult.  The 
tongue  sheds  its  thick  coating  about  the  third  day  and  presents  the 
characteristic  bright  red  "raspberry"  tongue. 

The  urine  in  the  first  days  of  the  attack  shows  the  ordinary  con- 
centration of  the  febrile  state.  It  may  contain  traces  of  albumin,  which 
is  transient,  although  some  observers  claim  albumin,  renal  epithelium, 
and  red  blood  cells  are  common  in  the  initial  stage.  Diarrhoea  may 
accompany  the  initial  vomiting  and  prove  troublesome  during  the 
entire  course.  The  eruption  usually  lasts  from  four  to  six  days,  reaching 
its  brightest  intensity  on  the  third  day.  It  recedes  in  the  order  of  its 
appearance,  becoming  gradually  less  distinct,  the  skin  assuming  a  yel- 
lowish stain,  which  is  last  seen  on  the  dorsum  of  the  hands.  As  a  rule 
the  temperature,  which  shows  a  morning  and  evening  fluctuation  of  a 
degree  or  more,  follows  the  rash  by  lysis  and  reaches  normal  a  day  or 
two  after  the  disappearance  of  the  rash.  Occasionally,  without  evident 
complication,  the  temperature  fluctuates  between  100°-102°  F.  (38°-39° 
C.)  throughout  the  second  week,  or  it  may  run  a  subnormal  course  for 
a  few  days.  Even  before  the  onset  of  symptoms  the  blood  shows  a  marked 
leucocytosis,  which  increases  with  the  appearance  of  the  rash  and  may 
reach  as  high  as  20,000  per  C.c.  or  more  in  moderate  cases.  The  increase 
is  seen  principally  in  the  polynuclear  cells.  The  eosinophiles  remain 
normal  or  may  show  slight  increase.  Their  total  disappearance  always 
renders  the  prognosis  grave.  Erythrocytes  and  haemoglobin  show  slight 
diminution,  while  in  protracted  cases  the  anaemia  is  pronounced.  During 
the  height  of  the  eruption  there  is  considerable  itching  of  the  skin, 
especially  noticeable  about  the  hands  and  feet,  which  appear  swollen. 
The  face  may  also  have  a  swollen  appearance,  while  the  eyes,  although 
rarely  deeply  injected,  are  usually  brilliant. 

A  day  or  two  after  the  subsidence  of  the  rash,  desquamation  begins, 
being  usually  most  marked  in  areas  of  greatest  eruption.  The  exfolia- 
tion of  the  trunk  occupies  six  to  ten  days  and  occurs  in  fine  furfuraceous 
scales.  That  of  the  extremities  continues  longer,  the  thickened  skin 
from  the  palmar  surfaces  of  the  fingers  and  toes  coming  away  in  large 
patches  or  casts.  This  is  peculiarly  characteristic  of  scarlet  fever  and 
may  require  from  four  to  six  weeks  for  its  completion.  In  uncompli- 
cated cases,  with  the  decline  of  the  temperature  the  angina  disappears, 
the  appetite  returns,  and  the  child  makes  a  rapid  convalescence. 

Instead  of  the  case  just  described,  all  of  the  symptoms  may  be  inten- 
sified and  the  stage  of  hyperpyrexia  prolonged,  marking  a  more  severe 
type  of  the  disease,  indicative  of  profound  sepsis. 

Variations  from  this  type,  as  before  mentioned,  are  frequent,  some 
of  which  have  given  rise  to  the  terms  scarlatina  sine  eruptione.  sine 
febre,  sine  angina,  also  scarlatina  hemorrhagica  and  scarlatina  maligna. 
The  rash  may  be  delayed  for  several  days  or  it  may  appear  in  circum- 


SCARLET    FEVER  545 

scribed  patches  as  a  local  erythema.  It  may  appear  as  extremely  fine 
papules,  like  "goose  flesh,"  blotchy,  resembling  measles,  or  in  the  form  of 
numerous  small  vesicles. 

The  rash  may  recede  on  the  day  of  eruption,  to  reappear  or  not  a 
few  days  later.  The  hemorrhagic  form  is  marked  by  a  deep  purple 
color  of  the  eruption,  which  may  be  interspersed  with  petechia;.  Ecchy- 
moses  from  a  pea  to  a  hand-breadth  in  size  may  appear. 

The  throat  lesions  vary  greatly,  as  to  their  character  and  extent,  from 
simple  hyperemia  to  extensive  tonsillar  and  pharyngeal  inflammation 
and  even  gangrene  and  sloughing.  Pseudomembranous  angina  is  com- 
mon. In  this  there  is  coagulation  necrosis  involving  the  tonsils,  fauces, 
buccal  surfaces,  and  even  the  entire  pharyngeal  Avail,  with  a  plugging 
of  the  posterior  nares.  Clinically  the  pseudomembrane  can  not  be  dis- 
tinguished from  that  of  diphtheria,  from  which  it  differs  bacteriologi- 
cally.  Occasionally  the  membrane  appears  early  in  the  attack,  but  it  is 
usually  of  later  development  and  is  significant  in  proportion  to  the  area 
involved. 

In  scarlet  fever  there  is  a  tendency  to  adenitis  which,  in  severe  cases, 
may  result  in  glandular  suppuration.  Those  of  the  neck  show  most  ex- 
tensive suppuration,  while  the  axillary,  inguinal,  and  mesenteric  lymph- 
nodes  show  swelling,  and  there  may  be  considerable  splenic  enlargement. 

Complications. — The  middle  ear  is  a  common  seat  of  infection  through 
the  Eustachian  tube.  This  is  often  followed  by  a  purulent  discharge 
from  the  meatus  and  occasionally  by  bony  necrosis  of  the  mastoid  and 
tympanic  walls.  The  otitis  is  usually  bilateral  and  constitutes  the  most 
frequent  sequel  of  scarlet  fever.  It  may  occur  during  the  height  of  the 
attack  but  more  often  develops  in  the  second  week.  Acquired  deaf- 
mutism,  according  to  statistics,  owes  its  origin  in  a  large  proportion  of 
cases  to  scarlatinal  otitis.  From  the  middle  ear,  as  well  as  from  the 
accessory  nasal  sinuses,  meningitis,  cerebral  abscess,  and  sinus  thrombosis 
may  develop. 

Scarlatinal  arthritis  is  by  no  means  rare,  and  may  constitute  a  true 
suppurative  lesion  of  the  joints,  or  there  may  be  only  infiltration  and 
swelling  of  the  periarticular  tissues  accompanied  by  pain  and  fever. 
The  latter  form  may  appear  coincidently  with  the  eruption  or  as  a 
sequel  to  the  disease. 

Scarlatinal  nephritis  is  one  of  the  common  complications  of  scarlet 
fever.  Indeed,  by  the  nephritis  alone  an  atypical  attack  of  scarlatina 
is  occasionally  diagnosed.  It  may  occur  during  the  height  of  the  attack 
as  an  acute  diffuse  nephritis,  although  it  is  rarely  attended  at  this  stage 
by  much  cedema.  The  renal  complication  generally  develops  ten  to 
thirty  days  after  the  subsidence  of  the  rash  and  during  apparent  con- 
valescence. The  first  indication  may  be  seen  in  diminution  or  sudden 
suppression  of  the  urine,  often  with  a  history  of  exposure  to  cold.  The 
swelling  of  the  eyes  and  puffiness  of  the  face  and  feet  point  to  the  nature 
of  the  complication.  This  is  confirmed  by  the  urinary  findings.  The 
heart  occasionally  suffers  in  scarlatina  from  endo-,  mvo-,  or  pericarditis, 

35 


546  THE    SPECIFIC    INFECTIOUS    DISEASES 

and  a  retrocedent  rash  may  be  the  first  intimation  of  cardiac  involve- 
ment. Most  frequently  cardiac  involvement  is  seen  in  conjunction  with 
the  post-scarlatinal  nephritis  before  mentioned. 

Bronchopneumonia  may  complicate  scarlet  fever,  especially  if  there 
be  profound  sepsis,  in  which  case  it  is  an  early  complication  and  con- 
tributes to  a  fatal  termination.  Later  pleuropneumonia  may  occur  with 
empyema,  or  oedema  of  the  lungs  may  accompany  nephritis. 

In  addition  to  the  above-mentioned  complications  and  pysemic 
processes,  resultant  from  general  and  local  infection,  scarlet  fever  may 
be  accompanied  by  any  of  the  acute  infectious  diseases,  in  which  event 
the  diagnosis  must  be  made  from  the  preponderance  of  symptoms,  the 
differential  findings,  and  the  history  of  exposure.  The  concomitant  or 
successive  occurrence  of  the  characteristic  rash  of  different  exanthems 
presents  many  puzzling  anomalies  to  the  diagnostician.  The  importance 
of  diagnosis  in  these  cases  is  self-evident,  not  only  in  relation  to  the 
prognosis,  but  for  its  prophylactic  value  concerning  other  children  who 
may  have  been  exposed. 

Diagnosis. — The  diagnosis  of  a  typical  case  of  scarlet  fever  presents 
few  difficulties.  In  the  atypical  cases  there  is  usually  present  some  one 
of  the  cardinal  symptoms,  such  as  the  raspberry  tongue,  and  later  the 
desquamation  and  McCollom's  white  line  at  the  junction  of  the  nails  and 
the  flesh.  Efflorescence  from  a  variety  of  causes  may  simulate  that  of 
scarlet  fever.  Medicinal  rashes  from  the  administration  of  quinine, 
belladonna,  antitoxins,  and  antipyrin,  are  to  be  distinguished  by  the 
history  of  the  medication  and  absence  of  other  confirmatory  signs  of 
scarlet  fever.  A  local  erythema,  indistinguishable  from  that  of  scarla- 
tina, may  be  due  to  rubefacients, — as  kerosene  oil,  turpentine,  "capsi- 
cine, "  etc. 

In  all  anginas,  cultures  should  be  examined  for  Klebs-Loemer  bacilli. 
For  a  comparative  diagnosis  from  measles,  varicella,  variola,  and 
rotheln,  see  table,  page  560. 

Prognosis.— The  prognosis  in  scarlet  fever  should  always  be  guarded, 
since  even  in  mild  cases  complications,  such  as  suppurative  otitis,  endo- 
carditis, and  nephritis,  may  arise.  As  in  other  disorders,  personal 
idiosyncrasy  has  much  to  do  with  the  course  and  complications  of  scarlet 
fever.  High  temperature,  above  105°  F.  (40.5°  C),  at  the  onset,  with 
persistent  vomiting,  portends  a  severe  attack,  while  extensive  throat 
involvement,  with  or  without  Klebs-Loemer  bacilli,  must  always  be 
regarded  with  apprehension.  Sudden  retrocession  of  the  rash  is  a  danger 
signal  and  should  lead  to  a  careful  examination  for  cardiac  or  pulmonary 
inflammations.  The  appearance  of  petechia?,  suggestive  of  the  hemor- 
rhagic type,  is  always  of  grave  import.  A  sudden  increase  in  leucocytes 
to  25,000  or  30,000  C.c.  indicates  extensive  suppuration. 

In  the  malignant  form  death  may  occur  in  the  second  or  third  day 
from  the  overwhelming  intoxication.  In  this  form  no  rash  may  have 
developed  or  the  eruption  may  be  hemorrhagic.  The  attack  may  begin 
with  convulsions,  or  early  coma  may  supervene,  from  which  the  child 


SCARLET    FEVER  547 

never  recovers.  The  temperature  is  high  (105°-107°  F.,  40.5°-41.5°  C), 
or  it  may  not  rise  above  100°  F.  (38°  C),  with  weak,  irregular  pulse, 
pale,  cyanotic  skin,  and  stupor  from  which  the  child  cannot  be 
aroused. 

The  nephritis  of  scarlatina  usually  terminates  favorably.  This  is 
especially  true  of  the  renal  complication  which  develops  as  a  sequel  and 
which  runs  a  course  of  an  acute  parenchymatous  inflammation.  The 
nephritis  occurring  at  the  height  of  the  attack  is  likely  to  prove  more 
serious  by  the  addition  of  uremic  to  the  scarlatinal  intoxication.  Ar- 
thritis in  the  purulent  form  is  a  dangerous  complication  from  the  pos- 
sibility of  septic  endocarditis.  Epidemics  differ  widely  in  their  mor- 
tality. From  the  reports  of  numerous  epidemics,  as  well  as  from  several 
large  hospitals  and  institutions  for  children,  the  average  mortality  of 
scarlet  fever  may  be  fairly  stated  as  from  ten  to  twelve  per  cent,  for 
children  of  all  ages,  under  five  years  about  twenty  per  cent.,  while  in 
young  infants  this  disease  shows  a  much  higher  fatality. 

While  scarlet  fever  rarely  occurs  in  the  same  individual  more  than 
once,  cases  are  recorded  of  a  second  and  even  a  third  attack,  usually  after 
an  interval  of  years.  As  in  typhoid  fever,  true  relapse  may  occur  from 
reinfection,  in  which  event  the  symptoms  and  complications  are  likely 
to  be  more  severe  than  in  the  primary  attack.  In  case  of  true  relapse 
the  temperature,  which  had  fallen  to  about  normal,  suddenly  rises,  and 
although  desquamation  may  have  been  well  under  way,  an  efflorescence 
spreads  over  the  body.  The  tongue  again  becomes  coated  and  the  angina 
reappears  with  increased  intensity.  In  contradistinction  to  the  above, 
cases  of  pseudorelapse  are  not  iTncommon.  These  amount  to  little  more 
than  a  recrudescence  of  the  eruption  before  the  beginning  of  desquama- 
tion. All  the  symptoms  of  the  early  stage,  including  fever,  angina,  and 
anorexia,  may  return  and  persist  for  a  week  or  more. 

Treatment. — No  specific  treatment  is  recognized.  Sera  have  proved 
disappointing,  although  recently  Escherich  has  endorsed  the  Moser  serum 
which  he  claims  has  reduced  the  mortality  by  half.  It  should  be  remem- 
bered that  the  disease  is  self-limiting,  running  a  fairly  definite  course 
with  a  tendency  to  recovery  in  the  absence  of  complications.  A  recog- 
nition of  the  complications  will  enable  the  physician  to  meet  the  impend- 
ing danger  and  intercept  some  of  its  most  serious  consequences.  The 
high  temperature,  unless  unduly  prolonged,  calls  for  no  special  treat- 
ment. The  use  of  antipyretic  drugs  should  be  discouraged,  not  only  as 
causing  disturbances  of  the  digestive  tract  but  as  tending  to  weaken  the 
heart.  The  proper  application  of  hydrotherapy  conduces  to  the  com- 
fort of  the  patient  and  reduces  the  temperature,  develops  or  maintains 
the  eruption,  and  promotes  elimination.  The  method  of  bathing  should 
depend  upon  the  conditions  in  the  individual  case.  If  the  skin  be  hot 
in  proportion  to  the  temperature  shown  in  the  rectum,  the  graduated 
full  bath,  beginning  at  98°  and  reducing  to  75°  (37°-24°  C),  for  five 
minutes,  may  prove  beneficial.  The  pack  at  a  temperature  of  75°  F. 
(24°   C.)   may  be  repeated  several  times  a  day  if  for  any  reason  the 


548  THE    SPECIFIC    INFECTIOUS    DISEASES 

cold  bath  be  impracticable.  Tepid  sponging  may  be  employed  at  a  tem- 
perature comfortable  to  the  patient.  Frequent  inunctions  of  the  entire 
surface  of  the  body  with  boric  acid,  two  per  cent,  in  vaseline,  or  of  one 
per  cent,  carbolic  acid  ointment,  tends  to  allay  the  pruritus,  promote 
sleep  by  relief  of  irritation  from  the  desiccating  effect  of  the  high  tem- 
perature, and  limit  the  spread  of  contagion  during  the  stage  of  des- 
quamation. 

The  early  vomiting  will  rarely  require  treatment,  as  it  is  usually 
limited  to  the  first  day.  Of  special  importance,  but  too  frequently 
neglected,  is  the  treatment  of  the  angina.  It  is  believed  that  the  in- 
tensity of  the  systemic  infection  may  be  positively  limited  by  early  and 
persistent  disinfection  of  the  throat  and  nasopharynx.  Bland  antiseptic 
alkaline  solutions  should  be  used  in  gargles,  also  in  sprays  and  douches, 
in  both  the  throat  and  nose.  A  flexible  rubber  tube  attached  to  the 
nozzle  of  a  fountain  syringe  will  answer  the  purpose.  On  account  of 
its  action  on  the  already  threatened  kidneys,  potassium  chlorate,  so 
frequently  used  in  throat  affections,  is  contraindicated. 

Symptoms  of  otitis  media  must  be  constantly  looked  for  and  incision 
of  the  drum  membrane  should  be  made  at  the  first  appearance  of 
pressure.  Early  operation  for  drainage  in  mastoiditis  may  avert  the 
fatal  consequences  of  deeper  infection.  Extensive  cervical  adenitis  is 
best  treated  by  the  ice  collar.  Incision  of  the  enlarged  glands  is  not 
recommended  in  the  absence  of  unmistakable  evidence  of  pus.  The 
possibility  of  renal  insufficiency,  both  as  an  early  and  late  complication, 
calls  for  the  free  administration  of  water.  Repeated  high  copious  entero- 
clysis  of  hot  saline  solution,  100°-110°  F.  (38°-43°  C),  undoubtedly 
promotes  elimination  from  the  kidney.  Upon  the  first  occurrence  of 
urinary  suppression  saline  diuretics,  as  potassium  acetate  and  citrate, 
may  be  given  with  or  without  digitalis.  A  weak  and  irregular  pulse 
calls  for  digitalis  or  caffeine  to  counteract  cardiac  insufficiency.  This, 
if  accompanied  by  a  retrocedent  rash,  should  be  met  by  nitroglycerin, 
given  hypodermic-ally,  every  hour  or  two. 

The  practice  of  administering  urotropin  throughout  the  attack,  as  a 
prophylactic  against  nephritis,  has  been  claimed  to  lessen  the  frequency 
of  that  complication.  Highly  septic  cases,  with  signs  of  prostration,  call 
for  the  use  of  alcohol  unless  specially  contraindicated  by  the  condition 
of  the  kidneys.  In  this  case  camphor  or  strychnia  may  be  substituted, 
although  the  latter  drug  is  not  as  efficient  in  scarlatina  as  in  some  other 
conditions. 

The  proof  or  the  strong  probability  of  the  presence  of  diphtheritic 
infection  demands  the  immediate  injection  of  antitoxin,  2000  to  5000 
units. 

The  arthritis  rarely  requires  specific  treatment  further  than  applica- 
tion of  anodyne  embrocations  and  cotton  wool  to  the  painful  joints. 
Evidence  of  cellular  or  synovial  suppuration  should  receive  prompt 
surgical  attention. 

The  early  vomiting  and  anorexia  will  prevent  dietetic  errors  unless 


MEASLES  549 

food  is  unwisely  forced  upon  the  unwilling  patient.  Indigestion  but 
adds  another  element  of  intoxieation.  Upon  the  subsidence  of  the  hyper- 
pyrexia, bland  liquid  nourishment  may  be  cautiously  administered. 
Except  in  rare  cases  the  best  representative  of  this  type  of  food  is  milk. 
Next  in  order  come  animal  broths  and  cereal  gruels,  with  fresh  fruit 
juices ;  later,  blanc-mange,  light  porridges  and  puddings,  ice-cream, 
custard,  eggs  cooked  soft,  a  little  jelly  from  fruits  or  meats,  and  toast, 
may  be  added.  It  should  be  remembered  that  according  to  present  teach- 
ing a  concentrated  nitrogenous  diet  increases  the  eliminative  work  of  the 
kidneys  and  is  contraindicated  in  view  of  the  possible  later  renal  com- 
plication. For  the  same  reason,  increased  metabolism  incident  to  exer- 
cise should  be  guarded  against  by  keeping  the  child  quiet  throughout 
the  danger  period  of  convalescence.  A  tendency  to  acidosis  from  dimin- 
ished ingestion  of  food  and  increased  metabolism  should  be  met  by  the 
use  of  alkaline  salts,  either  by  mouth  or  by  high  enteroclysis  of  saline  or 
alkaline  solutions. 

At  the  onset  of  the  attack  the  child  should  be  put  to  bed  and  kept 
there,  no  matter  how  mild  the  symptoms,  since  it  is  well  known  that 
grave  complications  may  develop  in  apparently  light  attacks.  Teaching 
and  practice  vary  widely  as  to  the  length  of  time  quarantine  should  be 
maintained.  The  protection  of  others  requires  sequestration  while  des- 
quamation is  in  progress  and  until  the  nasal  and  pharyngeal  mucous 
membranes  are  normal,  although  that  process  may  take  seven  or  eight 
weeks. 

MEASLES — RUBEOLA    MORBILLI. 

Measles  is  a  highly  contagious  acute  disease  distinguished  by  a  char- 
acteristic eruption  on  the  skin  and  mucous  membranes.  No  age  is 
exempt,  except  through  immunity  gained  by  a  previous  attack.  Many 
instances  of  recurrence  have  been  observed.  The  suckling  period  shows 
a  lessened  susceptibility  to  the  infection,  yet  cases  are  reported  as  early 
as  the  second  week  of  life,  and  the  possibility  of  congenital  measles 
from  infection  in  utero  is  admitted.  The  disease  occurs  regardless  of 
race  or  climate,  in  epidemics,  the  severity  of  which  seems  to  increase  with 
the  length  of  the  intervening  period. 

The  infectious  agent  in  measles  is  unknown.  That  it  is  present 
during  the  entire  course  of  the  disease  is  evident,  and  that  it  may  be 
air-borne  there  is  little  reason  to  doubt.  "Artificial  measles"  has  been 
induced  by  inoculation  with  blood  serum  taken  from  patients  during  the 
eruption. 

The  vitality  of  the  infecting  organism  and  the  danger  of  inter- 
mediary infection  is  much  less  than  in  scarlatina,  while  the  susceptibility 
is  more  universal. 

The  period  of  incubation  in  measles  is  from  seven  to  fourteen  days 
(usually  averaging  about  ten  days),  although  variations  occur  in  both 
directions. 

The  constant  lesion  of  measles  is  a  mild  inflammation  of  the  skin 
and  mucous  membranes,  with  perivascular,  periglandular,  and  perifol- 


550  THE    SPECIFIC    INFECTIOUS    DISEASES 

lieular  infiltration  of  ronnd  cells  in  the  corium  and  rete.  This  is  accom- 
panied by  an  acnte  catarrhal  condition  of  the  upper  respiratory  and 
conjunctival  mucosa,  with  swelling  of  the  cervical  and  bronchial  glands. 
There  is  hyperemia  of  the  oral  and  intestinal  mucous  membrane,  with 
tumefaction  of  Peyer's  patches  and  occasionally  acute  degenerative 
changes  in  the  kidneys.  The  conjunctivitis,  rhinitis,  laryngitis,  and 
bronchitis  preceding  and  accompanying  the  eruption  of  measles  are 
therefore  simply  expressions  of  the  disease  and  not  complications.  Varia- 
tions in  the  severity  and  extent  of  the  mucous  lesions  depend  upon  the 
character  of  the  micro-organisms  present,  among  which  the  the  staphylo-, 
strepto-,  and  pneumococcus,  alone  or  associated,  all  of  which  find  in 
the  catarrhal  mucosa  favorable  conditions  for  development.  Examina- 
tions of  the  blood  show  normal  or  diminished  leucocyte  count,  the  latter 
amounting  frequently  to  only  fifty  per  cent,  during  the  exanthem.  The 
eosinophiles  are  diminished  or  absent  during  the  pyrexia. 

Symptoms. — The  onset  of  measles  is  usually  gradual,  the  prodromal 
period  occupying  three  or  four  days.  The  child  is  listless,  drowsy,  or 
irritable,  refuses  food,  and  shows  some  fever,  coryza,  and  dry  cough. 
The  temperature  may  be  high  the  first  night  (102°  to  104°  F.  (39°-40° 
C),  in  which  case  it  usually  falls  two  or  three  degrees  in  twenty-four 
hours,  only  to  rise  again  a  day  later.  The  acceleration  of  pulse  and  respi- 
ration are  proportionate  with  the  elevation  of  temperature,  which  shows 
morning  remission.  The  palpebral  conjunctivae  look  moist  and  some 
congestion  at  the  inner  canthi  is  present.  The  tongue  is  coated,  breath 
feverish,  the  palate  is  hyperasmic  and  shows  dark  red  papules  bearing 
on  their  crests  minute  vesicles.  The  arrangement  of  these  papules  is 
very  suggestive  of  the  exanthem  as  it  appears  later  upon  the  skin.  In 
a  majority  of  cases,  Koplik's  sign  may  be  seen  on  the  buccal  mucosa. 
It  consists  of  minute  bluish  white  specks  with  a  large  irregular  areola 
of  rose-colored  mucosa,  separated  at  first  by  the  normal  pink  tint.  Later, 
as  the  hyperemia  extends,  these  specks  show  on  a  background  of  uni- 
form rose  color.  (See  Plate.)  Only  a  few  may  appear,  or  rarely  the 
entire  buccal  and  labial  mucosa  may  be  thickly  sprinkled  with  them. 
By  wetting  the  finger  these  specks  can  be  felt  as  minute  elevations 
which  may  be  removed  with  delicate  forceps.  Usually  good  daylight 
is  necessary  to  bring  out  this  sign  plainly. 

With  increasing  malaise  and  fever,  the  exanthem  makes  its  appear- 
ance about  the  fourth  day  of  onset, — first  on  the  temporal  region  and 
around  the  angles  of  the  nose  whence  it  rapidly  extends  over  the  face, 
scalp,  neck,  trunk,  and  extremities,  reaching  its  maximum  in  from 
thirty-six  to  forty-eight  hours.  Although  usually  quite  regular  in  this 
order  of  development,  the  rash  may  occasionally  appear  first  upon  the 
back  or  other  portions  of  the  trunk. 

The  exanthem  of  measles  is  rose-red,  irregularly  maculo-papular, 
primarily  discrete,  and  somewhat  crescentric,  both  in  form  and  in  their 
arrangement  into  clusters.  In  well-marked  cases  the  efflorescence  be- 
comes confluent  or  blotchy  over  large  areas,  and  the  parts  are  distinctly 


Fig.  1. 


KlG.    2. 


Fig. 


Fig.  4. 


Fig.  'JOS— The  Pathognomonic  Sign  of  Measles  (Koplik's  Spots). 

Fig.  1. — The  discrete  measles  spots  on  the  buccal  or  labial  mucous  membrane,  showing  the  isolated 
rose-red  spot,  with  the  minute  bluish-white  centre,  on  the  normally  colored  mucous  membrane. 

Fig.  2. — Shows  the  partially  diffuse  eruption  on  the  mucous  membrane  of  the  cheeks  and  lips 
patches  of  pale  pink  interspersed  among  rose-red  patches,  the  latter  showing  numerous  pale  bluish- 
white  spots. 

Fig.  3. — The  appearance  of  the  buccal  or  labial  mucous  membrane  when  the  measles  spots  com- 
pletely coalesce  and  give  a  diffuse  redness,  with  the  myriads  of  bluish-white  specks.  The  exanthema 
on  the  skin  is  at  this  time  generally  fully  developed. 

FIG.  4.— Aphthous  stomatitis  apt  to  be  mistaken  for  measles  spots.  Mucous  membrane  normal  in 
line.    Minute  yellow  points  are  surrounded  by  a  red  area.    Always  discrete.— Med.  News,  June  3,  1S99. 


MEASLES  551 

swollen.  This  is  particularly  true  of  the  face  which,  with  the  conjunc- 
tivitis, photophobia,  and  coryza,  presents  tin-  typical  physiognomy  of 
measles. 

At  the  height  of  the  eruption  the  temperature  begins  to  decline, 
reaching  normal  in  about  three  days,  although  usually  the  fall  is  abrupt. 
The  efflorescence  fades  from  above  downwards;  the  swelling  subsides, 
so  that  in  about  four  days  the  skin  shows  only  brownish  stains,  gradu- 
ally disappearing  with  a  fine  branny  desquamation  which  frequently 
escapes  notice.  Desquamation  is  nearly  complete  in  about  two  weeks 
from  the  first  appearance  of  the  exanthem. 

The  photophobia,  lachrymation,  coryza,  angina,  laryngitis,  and  bron- 
chitis reach  their  height  with  that  of  the  pyrexia,  and  gradually  subside 
with  the  disappearance  of  the  rash  and  subsequent  desquamation,  while 
ocular  and  bronchial  irritability  may  persist  for  some  time. 

ATYPICAL    MEASLES — COMPLICATIONS    AND    SEQUEL.E. 

Measles  may  run  its  course  with  no  eruption  on  the  face,  or  the 
exanthem  may  appear  irregularly  on  different  portions  of  the  body, 
or  be  entirely  wanting.  The  rash  may  develop  tardily,  requiring  some- 
times from  five  to  twenty  days,  and  occasionally  it  is  neither  preceded 
by  prodromata  nor  accompanied  by  fever.  The  full  efflorescence  may 
suddenly  disappear  under  the  influence  of  some  visceral  inflammation, 
or  any  condition  which  diminishes  the  volume  of  blood  in  the  superficial 
capillaries.  The  cutaneous  congestion  may  be  so  intense  as  to  cause 
minute  extravasation  of  blood  into  the  eruption.  This  is  known  as 
hemorrhagic  or  "black  measles."  Sometimes  the  papules  show  minute 
yellow  vesicles  on  their  apices,  morbilli  miliaria.  The  eruption  may  vary 
widely  from  the  maculo-papular  type  to  that  of  a  mild  erythema  which 
may  be  confined  to  the  face  or  appear  upon  portions  of  the  trunk.  The 
crescentric  arrangement  is  occasionally  replaced  by  a  discrete  punctate 
papular  eruption  on  the  forehead  and  parts  of  the  body. 

Relapses  occur  after  an  interval  of  a  week,  in  which  the  exanthem 
is  repeated,  and  measles  may  recur  after  several  weeks,  and  repeat  the 
process  even  to  the  third  attack. 

The  complications  are  usually  outgrowths  of  disorders  of  the  mucosa 
incident  to  the  disease,  nor  is  it  strange  that  resident  bacteria  should 
become  pathogenic  under  these  catarrhal  conditions,  nor  that  the  affected 
membranes  should  afford  favorable  soil  for  accidental  infections.  Thus 
the  nose,  pharynx,  and  larynx  are  the  common  seat  of  lesions  which 
produce  cough,  aphonia,  and  obstruction  to  respiration,  so  that  in  the 
infant,  nursing  may  be  difficult  or  impossible.  Pseudomembranes  may 
form  on  these  parts  from  diplococcic  invasion,  and  Klebs-Loeffler  diph- 
theria is  especially  to  be  dreaded.  Extension  to  the  middle  ear.  with 
mastoid  suppuration,  is  not  rare,  while  every  form  of  stomatitis  and 
angina  may  be  encountered.  The  swollen  lymph-nodes  to  which  the 
channels  of  these  areas  are  tributary  attest  the  intensity  of  the  local 
infection.      Thrombosis   and   gangrene   of   the   skin    and   subcutaneous 


552  THE    SPECIFIC    INFECTIOUS    DISEASES 

tissues  about  the  mouth,  face,  genitals,  and  extremities  are  not  rare 
in  severe  measles. 

The  commonest  serious  complications  are  capillary  bronchitis  and 
atelectasis,  especially  in  infants;  also  bronchopneumonia  as  an  exten- 
sion of  the  catarrhal  bronchitis  peculiar  to  the  disease.  Occasionally 
fibrinous  pneumonia  may  develop,  with  accompanying  pleuritis,  while 
tuberculosis,  either  from  processes  latent  or  acquired,  in  the  form  of 
miliary  lesions,  is  a  too  common  sequel.  The  intestinal  tract  may  suffer 
from  any  of  the  catarrhal  and  structural  lesions  peculiar  to  that  area. 
Earely  the  kidneys  suffer  from  extensive  degenerative  changes,  and  but 
few  instances  of  nephritis  following  measles  have  been  observed.  The 
eyes  may  be  seriously  affected  with  blepharitis,  conjunctivitis,  and  kera- 
titis, in  chronic  form,  and  the  photophobia  causing  blepharospasm  may 
lead  to  persistent  tic.  The  heart  shows  no  marked  tendency  to  lesions 
further  than  the  slight  ventricular  dilation  incident  to  a*ll  acute  infec- 
tious fevers.  Occasionally,  however,  especially  with  extensive  broncho- 
pneumonia, endo-,  peri-,  and  myocarditis  develop.  The  nervous  symp- 
toms are  not  usually  marked.  Occasionally  in  infants,  the  initial  fever 
is  ushered  in  with  convulsions.  Stupor  and  coma  are  seen  in  severe 
hemorrhagic  cases,  and  rare  instances  of  post-febrile  polyneuritis  with 
paraplegia  have  been  reported.  Pertussis  as  a  complication  or  sequel 
is  much  to  be  dreaded,  especially  in  the  winter  and  in  young  children, 
as  the  accompanying  bronchitis  or  bronchopneumonia  help  to  form  a 
vicious  circle  from  which  complete  recovery  is  rare. 

Diagnosis. — The  diagnosis  of  atypical  measles  from  a  number  of 
diseases  and  conditions — such  as  scarlatina,  rubella,  varioloid,  influenza, 
acute  eczema,  syphilitic  roseola,  and  the  rashes  due  to  drugs  or  anti- 
toxin— may  at  times  be  difficult.  Koplik's  spots  should  always  be  sought 
for  in  good  daylight,  as  their  presence  or  absence  will  clear  up  many 
otherwise  doubtful  cases.  The  presence  of  cough,  hoarseness,  coryza, 
fever,  and  Koplik's  sign  will  establish  the  diagnosis  before  or  during 
the  exanthem,  whatever  may  be  the  character  of  the  latter.     (See  Plate.) 

The  leucopenia  and  the  paucity  or  entire  absence  of  the  eosinophiles 
in  measles,  will  help  to  differentiate  from  scarlatina,  in  which  disease 
leucocytosis  is  marked  and  eosinophilia  is  usually  present.  Increase  in 
white  blood  corpuscles  is  also  the  rule  in  syphilitic  roseola.  In  other 
doubtful  cases  the  history  of  onset  and  the  absence  of  the  typical 
buccal  and  throat  signs  of  measles  should  exclude  that  disease.  It 
should  never  be  forgotten  that  measles  and  other  exanthemata  may 
coexist  with  a  blending  and  modification  of  their  characteristic  signs 
and  symptoms. 

Prognosis. — The  prognosis  depends  so  largely  upon  the  complication, 
environment,  and  the  patient's  age  that  no  tabulation  of  statistics  can 
be  of  much  value.  In  infants  under  two  years  the  mortality  of  measles 
is  very  high,  especially  in  institutions,  where  it  exceeds  fifty  per  cent. 
In  private  practice,  with  fair  nursing  and  surroundings,  four  per 
cent,    of   deaths   in   older   children   would   be   a   high   estimate.      The 


MEASLES 

indirect  mortality  and  morbidity,  however,  emphasize  measles  as  the 
dread  disease  of  early  childhood.  That  this  fad  is  rarely  recognized 
by  the  laity  should  increase  the  alertness  of  physicians  who  appreciate 
its  significance. 

Among  the  grave  indications  in  measles  may  be  mentioned  high 
febrile  onset,  intense,  rapidly  developing  rash  of  dark  hue,  especially 
of  hemorrhagic  type,  retarded  eruption,  recession  of  the  rash,  which 
points  to  heart  failure,  or  to  severe  visceral  complication.  A  continued 
high  fever  after  the  second  day  of  efflorescence  is  always  suggestive  of 
accidental  infection  which,  if  the  ratio  of  respiration  to  pulse  be  in- 
creased, is  probably  pneumonia.  Chronic  bronchitis,  bronchiectasis, 
adenoids,  and  the  ever-threatening  tuberculosis  as  sequela?,  give  to 
measles  an  importance  not  exceeded  by  any  other  acute  disease  of  child- 
hood. 

Treatment. — As  a  self-limiting  disease  of  unknown  etiology  measles 
has  no  specific  curative  treatment.  Proper  management  will  do  much 
to  mitigate  its  severity  and  forestall  complications.  The  child  should 
be  put  to  bed,  with  light  covering,  in  a  well-ventilated  room  with  an 
even  temperature  of  about  68°  F.  (20°  C).  After  the  first  cleaning 
out  with  a  mild  laxative  (castor  oil)  the  bowels  should  not  be  teased  by 
cathartics.  When  necessary,  bland  enemeta  may  be  administered.  The 
eyes  must  be  protected  from  bright  light,  cleansed  frequently  with  boric 
acid  solution,  and  the  lids  anointed  with  vaseline  if  necessary  to  prevent 
agglutination.  The  nose,  mouth,  and  throat  should  be  sprayed  freely 
and  often  with  Seller's  solution  to  limit  extension  of  infection  to  larynx, 
bronchi,  and  intestinal  tract.  Tepid  or  warm  sponge  baths  two  to  four 
times  daily  will  promote  comfort  and  lessen  fever,  as  will  also  inunc- 
tions of  carbolized  vaseline  or  borated  lard  (Formulas  33,  34). 

The  child  should  be  kept  on  fluid  diet  and  encouraged  to  drink  water 
freely,  which  need  not  necessarily  be  warm.  The  feet  must  be  kept  warm 
and  the  head  cool,  the  latter  with  ice-cap  if  necessary.  The  eruption, 
if  delayed,  may  be  promoted  by  hot  baths  and  hot  drinks.  A  sudden 
recession  of  the  efflorescence  also  requires  hot  applications  to  the  surface 
and  extremities,  and  the  internal  administration  of  hot  stimulants.  If 
the  cough  be  troublesome,  sodium  bromide  in  syrup  of  lactucarium  (For- 
mulas 20,  21,  22),  may  be  given  or,  if  necessary,  small  doses  of  codeine 
or  paregoric.  The  same  remedies  may  be  extended  for  restlessness.  The 
child  must  be  watched  carefully  for  threatened  complications,  which 
should  receive  early  and  appropriate  treatment. 

Strict  quarantine  should  be  maintained  and  the  child  kept  in  bed 
until  desquamation  is  well  advanced.  Seclusion  should  be  kept  up  for 
three  weeks  from  the  onset  of  symptoms,  in  the  most  favorable  cases, 
and  a  thorough  bath,  and  fresh  clothing,  should  be  given  before  the 
child  is  allowed  to  come  in  contact  with  others.  Subsequent  care  is 
necessary  for  several  weeks  to  guard  against  bronchial  and  eye  troubles. 
After  removal,  the  sick-room  must  be  thoroughly  cleaned  and  allowed 
to  air  for  a  week  before  further  occupancy. 


554  THE    SPECIFIC    INFECTIOUS    DISEASES 

Delicate  and  cachectic  children  should  be  protected  from  exposure 
to  measles  at  whatever  pains  and  expense. 

RUBELLA — ROTHELN    (GERMAN    MEASLES ). 

Rubella  is  a  distinct,  contagious,  eruptive  disease,  though  for  a 
long  time  after  its  recognition  by  competent  observers  it  was  refused 
a  place  in  the  nosology. 

Its  close  resemblance  to  rubeola  first  suggested  the  diminutive, 
rubella,  as  an  appropriate  name  and  as  such  it  is  generally  accepted  by 
the  profession  in  this  country.  On  the  continent,  especially  in  Germany 
and  Russia,  the  terms  rotheln  and  rubeola  are  used  synonymously,  to 
the  confusion  of  younger  students. 

The  etiology  of  rubella  is  unknown.  It  is  about  as  contagious  as 
rubeola  and  like  that  disease  it  rarely  appears  except  in  epidemics. 
The  period  of  incubation  is  from  one  to  three  weeks,  stage  of  invasion 
one  day,  and  stage  of  eruption  from  one  to  three  days. 

Symptoms. — General  malaise  and  slight  fever  may  precede  the  erup- 
tion by  a  day,  the  temperature  rarely  exceeding  102°  F.  (39°  C).  The 
tongue  is  slightly  coated  and  the  soft  palate  and  uvula  may  show  a  few 
rose  spots  about  the  size  of  a  pinhead.  The  post-cervical  lymph-nodes 
show  discrete  enlargement  in  most  cases,  although  the  anterior  cervical 
and  submaxillary  glands  are  rarely  affected.  Mild  catarrhal  symptoms 
may  be  present  but  are  not  constant. 

The  rash  appears  on  the  second  day,  occasionally  without  prodromata. 
It  consists  of  light  red  or  pink  maculo-papules  in  size  from  a  pinhead  to 
a  split  pea,  which  are  slightly  elevated  and  may  be  felt  with  the  finger. 
They  appear  first  on  the  face  and  spread  rapidly  over  the  body  and 
limbs,  disappearing  from  the  first  situation  by  the  time  the  feet  are 
reached.  The  eruption  is  usually  discrete,  and  sometimes  punctate  or 
hard  and  shot-like  to  the  touch.  At  other  times  it  is  more  macular  and 
tends  to  coalescence  in  large  areas.  The  temperature  falls  at  the  height 
of  the  exanthem,  which  rarely  remains  more  than  forty-eight  hours. 
Close  scrutiny  will  usually  detect  slight  furfuraceous  desquamation  on 
trunk  and  limbs. 

Complications  are  rare,  although  the  exanthem  may  occur  coinci- 
dently  with  other  acute  disorders.     There  are  no  characteristic  sequela?. 

Prognosis  is  good. 

Treatment. — Mild  laxatives  and  light  diet  are  all  that  is  necessary 
in  the  majority  of  cases.  The  child  should  be  isolated  from  the  rest  of 
the  family,  as  in  measles. 

It  is  in  the  diagnosis  that  rubella  assumes  any  particular  importance. 
It  is  so  frequently  confounded  with  rubeola  and  scarlatina  that  it  has 
received  much  attention  which  it  otherwise  would  not  merit.  From 
rubeola  it  is  distinguished  by  its  long  period  of  incubation,  short  stage 
of  invasion,  low  temperature,  lighter  shade  of  eruption,  which  is  rarely 
crescentric,  and  the  general  mild  character  and  brevity  of  the  disease. 
The  absence  of  Koplik's  spots,  also  of  pronounced  catarrhal  symptoms, 


SMALLPOX  555 

should  complete  the  diagnosis.  One  fairly  constant  feature  of  rubella 
is  an  enlargement  of  the  lymph-nodes  behind  tin-  sternocleidomastoid 
muscle.  From  scarlatina  it  should  readily  be  differentiated  by  the 
absence  of  high  temperature,  severe  angina,  raspberry-tongue,  confluent 
rash,  and  extreme  malaise  characteristic  of  that  disease. 

In  their  atypical  forms  Ihese  exanthemata  may  be  so  difficult  to 
distinguish  that  every  doubtful  case  should  receive  the  close  attention 
due  to  the  gravest  possibility,  and  sporadic  rubella  must  always  be  re- 
garded with  suspicion. 

VARIOLA — SMALLPOX. 

Variola  was  formerly  the  most  dreaded  of  the  acute  contagious  dis- 
eases. Since  the  prevalence  of  vaccination  the  immunity  to  this  infec- 
tion is  so  general,  and  its  supervision  by  health  officers  so  complete,  that 
the  general  practitioner  is  rarely  called  to  treat  it. 

The  limits  of  this  volume  will  allow  mention  only  of  some  points 
of  importance  in  diagnosis  from  the  common  exanthems. 

Variola  in  children  differs  in  no  essential  from  the  disease  as  it  occurs 
in  adults,  except  for  its  higher  mortality.  It  is  especially  fatal  in 
young  infants.  The  nature  of  the  infection  is  not  known  but  is  prob- 
ably due  to  bacteria  ultramicroscopic  in  character.  Its  vitality  is  well 
recognized,  as  the  disease  is  propagated  through  nearly  every  medium 
of  communication,  and  instances  are  known  in  which  years  have  elapsed 
between  infector  and  infectee,  the  virus  having  been  retained  in  clothing 
or  books  with  its  virulency  preserved  by  the  exclusion  of  light  and  moist- 
ure. The  susceptibility  to  smallpox  infection  is  almost  universal,  save 
in  those  immune  by  a  previous  attack  or  by  vaccination.  This  suscepti- 
bility varies  so  widely  in  degree  that  the  severity  of  an  attack  depends 
more  upon  the  personal  equation  than  upon  the  virulency  of  the  infec- 
tion, so  that  the  effects  of  a  contagion  can  never  be  premised  from  the 
degree  of  severity  exhibited  in  the  parent  case. 

The  period  of  incubation  lasts  from  one  to  three  weeks,  with  an 
average  of  thirteen  days.  The  prodromata  cover  three  or  four  days  and 
always  present  symptoms  of  severe  intoxication,  such  as  chill,  high 
temperature,  rapid  pulse,  malaise,  headache,  backache,  epigastric  pain, 
anorexia,  vomiting  and  delirium  or  convulsions. 

Young  infants  frequently  succumb  to  the  intense  toxa?mia  at  this 
stage.  A  rash,  somewhat  like  that  of  scarlatina,  is  frequently  seen  at 
this  time,  usually  on  the  abdomen  and  inner  side  of  the  thighs  and 
arms,  and  may  extend  to  the  chest  and  face.  It  is  transient,  however, 
and  gives  way  to  the  characteristic  exanthem  which  makes  its  appear- 
ance quite  regularly  on  the  fourth  day.  The  eruption  begins  on  the 
forehead,  appearing  soon  after  on  the  dorsum  of  the  hands  and  wrists, 
and  spreads  rapidly  over  the  body  and  limbs  until  no  portion  of  the 
integument  is  exempt. 

An  enanthem  involving  all  the  visible  mucosas  precedes  or  accom- 
panies the  exanthem. 

With  the  appearance  of  this  eruption  the  temperature  falls  from 


556  THE    SPECIFIC    INFECTIOUS    DISEASES 

three  to  five  degres  and  occasionally  reaches  normal.  In  discrete  variola 
the  skin  first  shows  small  red  macules  which  quickly  become  hard  papules, 
and  these  may  be  felt  like  small  shot  beneath  the  skin.  The  following 
day  each  papule  bears  a  tiny  vesicle  on  its  summit  which  enlarges  rapidly 
to  the  size  of  a  pinhead  or  split  pea  and  is  filled  with  clear  serum.  These 
lesions  are  surrounded  by  a  narrow  areola  of  hyperasmic  skin  and  are 
crossed  by  trabecular  which,  as  the  vesicle  becomes  more  distended, 
limits  the  epidermal  elevation,  causing  a  central  depression  or  umbilica- 
tion  characteristic  of  the  disease.  Gradually  the  vesicles,  which  were  at 
first  translucent,  become  opaque,  then  yellowish,  as  their  serum  changes 
to  pus,  so  that  by  the  eighth  day  of  the  attack  the  eruption  is  distinctly 
pustular  and  the  secondary  fever  develops. 

Good  illumination  will  show  the  same  sequence  of  changes  in  the 
enanthem,  somewhat  modified  by  the  different  character  of  the  tissues. 
The  vesicles  and  pustules  of  variola  are  also  peculiar  in  that  when 
punctured  they  do  not  collapse  as  in  varicella,  with  escape  of  all  the 
contents,  because  of  the  histological  difference  in  their  structure,  for, 
owing  to  the  involvement  of  the  rete  they  are  multi-cellular. 

In  confluent  smallpox  the  papules  are  more  numerous  and  the  vesicles 
coalesce,  which,  with  the  oedema  and  infiltration,  causes  in  the  pustular 
stage  such  extreme  bloating  as  to  render  the  patient  unrecognizable. 
The  mucosas  also  share  in  this  distortion.  The  odor  of  confluent  small- 
pox in  the  pustular  stage  is  never  to  be  forgotten. 

Diagnosis. — The  diagnosis  of  a  typical  case  presents  no  difficulties. 
In  the  form  modified  by  vaccination,  however,  and  known  as  varioloid, 
recognition  is  sometimes  quite  difficult,  as  all  the  symptoms  are  modified 
and  the  eruption  may  be  present  only  here  and  there  as  isolated  lesions. 
Occasionally  one  only  may  be  found  upon  the  entire  body.  In  doubtful 
cases  the  mucosas  should  be  carefully  inspected  by  a  good  light,  especially 
that  of  the  mouth,  prepuce,  and  vulva,  as  on  one  of  the  areas  a  tell-tale 
lesion  may  surely  be  found  if  the  case  be  varioloid.  No  other  disease 
presents  the  typical  character  and  sequence  of  dermal  lesions  and 
temperature.  In  every  suspicious  case  vaccination  should  be  promptly 
performed  upon  both  the  patient  and  members  of  the  household,  since 
the  modifying  influence  of  even  late  vaccination  is  well  recognized. 
After  this  the  case  should  be  reported  to  the  health  authorities,  as  no 
general  practitioner  can  afford  to  remain  in  charge  of  a  smallpox  pa- 
tient. 

For  the  course  of  the  disease  and  treatment,  see  standard  works  on 
practice. 

VACCINIA — COW-POX. 

Vaccinia  is  an  infectious  fever  induced  by  inoculation  with  cow-pox 
virus  obtained  from  calves,  artificially  infected  with  the  disease.  The 
vaccine  lymph  containing  the  virus  is  now  obtained  under  strict  aseptic 
precautions  and  kept  hermetically  sealed  until  required  for  use. 

The  arm  at  the  insertion  of  the  deltoid  is  usually  selected  as  a  most 
eligible  spot  for  the  inoculation,  and  should  be  prepared  with  all  the 


COW-POX  557 

care  essential  to  aseptic  surgery.  The  part  being  clean,  a  small  area  (one- 
fifth  of  an  inch,  5.0  Mm.)  of  the  epidermis  should  be  removed  by  teasing 
with  a  rather  dull  needle  or  pointed  ivory  vaccine  quill  until  the  serum 
oozes  through  the  abraded  surface.  No  blood  should  flow  to  wash  away 
or  attenuate  the  virus  and  delay  absorption. 

If  dry  virus  or  points  be  used,  a  drop  of  sterile  water  will  be  neces- 
sary to  moisten  the  quill.  Liquid  virus  in  sealed  glass  tubes  is  of  the 
proper  consistency.  This  should  be  gently  applied  to  the  abrasion  and 
rubbed  in  with  point  or  sterile  blade  and  allowed  to  dry,  after  which  an 
aseptic  dry  gauze  dressing  should  be  applied  and  retained  by  adhesive 
strips  for  a  week.  If  successfully  vaccinated  the  child  will  develop 
symptoms  of  vaccinia  at  the  end  of  five  or  six  days. 

Slight  fever,  malaise,  anorexia,  and  other  evidences  of  mild  intoxica- 
tion, usher  in  the  disease.  Some  children  are  quite  ill  and  are  put  to 
bed,  but  usually  the  symptoms  subside  in  two  or  three  days  with  no 
further  disturbance  than  the  discomfort  from  the  local  lesion.  This 
usually  shows  activity  by  the  fifth  or  sixth  day,  when  with  a  little  red- 
ness one  or  more  papules  develop,  quickly  changing  to  vesicles,  which 
increase  in  size  and  coalesce,  becoming  umbilicated  and  opaque.  By 
the  end  of  the  second  week  it  has  dried  into  a  firm,  dark  crust.  This 
scab  should  never  be  disturbed,  but  should  be  allowed  to  fall  off,  where- 
upon a  red  scar  appears  which  gradually  fades  in  color  and  remains 
permanent.  Sometimes  there  is  considerable  infiltration  around  the 
lesion,  with  brawny  induration  and  redness.  The  axillary  glands  are 
swollen  and  the  child  may  be  quite  ill. 

If  accidental  infection  of  the  wound  occur,  there  may  be  deep  and 
extensive  ulceration,  rarely  sloughing,  or  erysipelas.  A  variety  of  rashes 
and  transient  dermal  lesions  are  occasionally  encountered,  all  of  which 
should  receive  treatment  according  to  their  indication. 

The  child  should  not  be  vaccinated  if  sick,  very  delicate,  or  under 
three  months  of  age,  unless  in  the  presence  of  smallpox.  The  best 
time  to  vaccinate  is  in  the  late  spring  or  early  fall,  thus  avoiding  the 
extremes  of  temperature.  The  vaccination  should  be  repeated  every 
few  months  until  it  "takes,"  after  which  revaccination  should  be  per- 
formed evexy  three  to  five  years  to  test  immunity. 

VARIOLOID MODIFIED    SMALLPOX. 

That  vaccination  grants  immunity  from  variola  has  been  proven 
to  the  satisfaction  of  the  scientific  world.  In  many  this  immunity  is 
absolute,  as  seen  in  nurses  and  physicians  who  pass  unscathed  through 
epidemics,  although  brought  into  daily  contact  with  the  disease  in  all 
its  stages.  A  relative  immunity,  however,  is  quite  common,  especially 
among  children,  so  that  exposure  to  infection  induces  a  modified  form 
of  smallpox  (varioloid). 

Symptoms. — The  onset  may  be  as  severe  as  in  variola  vera,  but  the 
eruption  is  irregular  and  atypical  and  rapidly  dries  up.  Careful  ex- 
amination will  usually  disclose  one  or  more  somewhat  typical  vesicles, 


558  THE    SPECIFIC    INFECTIOUS    DISEASES 

most  frequently  on  the  mucosa  or  pseudomueous  membrane  about  the 
mouth,  eyes,  or  genitals. 

The  treatment  is  symptomatic  so  far  as  the  patient  is  concerned,  yet 
the  strictest  isolation  should  be  enforced,  with  every  precaution  on  the 
part  of  physician  and  attendants,  since  the  contagion  is  just  as  dan- 
gerous from  the  mildest  varioloid  as  from  the  most  pronounced  case  of 
variola. 

VARICELLA — CHICKEN-POX. 

Varicella  is  the  mildest  of  the  exanthemata.  "What  clinical  import- 
ance it  has  is  due  to  its  occasional  confusion  with  diseases  of  a  more 
serious  character,  as  variola  and  varioloid. 

The  incubation  period  lasts  for  from  one  to  three  weeks,  with  an 
average  of  about  fifteen  days.  It  is  essentially  a  disease  of  childhood, 
being  rarely  seen  after  puberty,  and  is  most  common  between  the  second 
and  tenth  year. 

Varicella  occurs  sporadically  and  in  epidemics,  is  highly  contagious, 
and  probably  air-borne,  while  its  specific  infectious  agent  is  unknown. 
It  has  been  reproduced  by  inoculation  with  serum  taken  from  the  vesicle 
at  the  height  of  eruption,  without  modification  of  the  disease,  save  in 
a  reduction  of  the  incubation  period  to  eight  days. 


Fig.  208.— Chicken-pox.    Third  day  of  eruption.    Bahy,  4  months. 

Immunity  is  conferred  by  a  previous  attack  of  the  disease,  and  to 
a  certain  extent  by  adult  age,  yet  exceptions  to  both  are  noted. 

The  prodromata  are  mild  and  not  characteristic.  There  may  or 
may  not  be  a  little  fever  and  malaise  for  a  day  or  two.  The  exanthem 
begins  on  the  back  or  chest  and  extends  irregularly  over  the  scalp,  trunk, 
and  limbs  with  but  little  involvement  of  the  face.  Simultaneously  with 
the  skin  the  mucosas  of  the  mouth,  pharynx,  prepuce,  vulva,  and  occa- 
sionally of  the  eyes  and  nose,  show  the  eruption. 

The  characteristic  lesion  consists  of  rose-red  macules,  round  or  oval, 
without  definite  arrangement  or  distribution,  changing  quickly  to  soft 


CHICKEN-POX 

papules  which  fade  under  pressure,  and  within  twenty-four  hours  be- 
come distinct  vesicles,  in  size  from  a  pinhead  to  that  of  a  large  split 
pea.  The  vesicles  are  discrete,  unicellular,  translucent,  and  filled  with 
clear  alkaline  serum.  They  rarely  become  pustular,  rarely  umbilicate, 
and  when  pricked  the  epidermis  flattens,  turns  dark,  dries  and  falls  off 
in  two  or  three  days,  leaving  occasionally  a  scar. 

A  peculiarity  of  this  exanthem  is  its  appearance  in  successive  irregu- 
lar crops,  three  or  more,  so  that  in  a  fully  developed  case  all  stages  of 
the  eruption  are  seen  side  by  side,  as  macule,  papule,  vesicle,  and  scab 
(Fig.  208). 

When  the  exanthem  is  developed  the  slight  fever  subsides,  only  to 
rise  again  with  each  successive  crop  of  macules,  if  they  be  abundant ; 
otherwise  the  temperature  is  about  normal. 

The  child  is  rarely  very  sick,  but  may  show  slight  angina  and  coryza 
for  a  day  or  two.  The  disease  usually  lasts  a  week,  and  in  uncomplicated 
cases  is  never  fatal. 

Complications. — The  pruritus  induces  scratching,  so  that  the  lesions 
may  become  infected  with  resultant  suppuration  and  pitting.  Gan- 
grenous areas  may  develop  (varicella  gangrenosa),  especially  in  poorly 
nourished  and  tuberculous  children.  Otitis,  pneumonia,  arthritis,  con- 
junctivitis, and  vulvitis  are  occasional  complications.  Nephritis  has  been 
reported  as  a  sequel  of  severe  varicella  by  a  few  observers,  although  it 
is  regarded  as  very  rare. 

Diagnosis. — During  epidemics  of  smallpox  the  difference  between 
varicella  and  that  disease  becomes  a  matter  of  great  importance.  The 
earlier  theory  of  a  relationship  between  the  two  exanthems  has  long 
since  been  disproved.  Quite  recently  mild  epidemics  in  the  middle  west- 
ern United  States  have  led  to  much  acrimonious  discussion  as  to  their 
true  character,  many  local  practitioners  maintaining  that  the  health 
authorities  wrongly  diagnosed  as  mild  variola  atypical  cases  of  varicella. 
As  between  typical  cases,  the  brevity  or  absence  of  prodromata  :  the  early 
eruption  of  vesicles  occurring  in  crops,  without  pustulation.  umbilica- 
tion,  or  cicatrization ;  the  short  duration ;  the  absence  of  immunity  from 
vaccination,  should  make  clear  the  diagnosis  of  varicella  from  variola. 
Herpes  zoster  follows  the  course  of  some  nerves  and  is  never  widely 
distributed. 

The  prognosis  is  invariably  good,  with  proper  care. 

Treatment. — The  treatment  is  entirely  symptomatic.  The  child 
should  be  kept  indoors  and  protected  from  changes  of  temperature. 
Diet,  care  of  the  bowels,  and  the  protection  of  other  children  against 
the  infection,  is  about  all  that  the  ordinary  case  requires.  The  lesions 
must  not  be  scratched.  Itching  may  require  ointment  of  boric  acid 
(1:20)  or  bismuth  subgallate  dusted  on  the  spot  of  irritation.  For 
mouth  and  throat  lesions,  a  teaspoonful  of  potassium  chlorate  solution 
(1:30)  may  be  gargled  and  swallowed  every  few  hours.  The  urine 
should  be  watched  for  the  rare  possibility  of  renal  complications. 


560 


THE    SPECIFIC    INFECTIOUS    DISEASES 


M 

En 
M 


O 
O 

r— I 

H 

<^ 

i— i 
Eh 


Eh 

P 

M 

Eh 


< 
u 

^  > 

<! 

o 

CO 

3 

3 

0? 

•G 

03      . 
!>   «3 
««? 

c  o 

"3 

One-half    to    one    day. 
Headache,  sore  throat, 
high  fever,  vomiting. 

Fir.st  or  second  day.    Dif- 
fuse punctate  red  rash  first 
on  neck,  soon  covers  b'  dy 
and    limbs,   but   usually 
spares   forehead  and  pro- 
labia,  which  are  white. 

Tonsillitis  and  red  points 
on  fauces.    Large  fungi- 
form  papillte   on   tongue. 
Later,  "raspberry-tongue." 

03   CD 

CD  ho 

03  3 

t.-r- 
-^  " 

la 
-  p 

03  o3 

High,    disappearing    by 
lysis  as  the  eruption  fades. 

Angina,  adenitis,  otitis, 
arthritis,    nephritis    endo- 
and  pericarditis. 

M 

o 

w 
M 

o 

3 
o 

<! 

iJ 
J 
H 

o 

5 

> 

03 

3  cc 

O  >> 

.S"0 

c  3 
03  s 

£  0) 

«1 

0)   CO 

t>  p 

CD  CO 
-O 

One  day  or  none.    Slight 
malaise  with  little  or  no 
fever. 

First  day.   Rose-red  mac- 
ules, quickly  changing  to 
papules  and  vesicles.  Clear 
serum,    not   umbilicated, 
dry  down  quickly.     Disor- 
derly repetition   of   crops 
showing  various  stages. 

1     CD 
03-3 
ft*3 

c£ 
OQ-rH 

03  ^ 
3 

§3 

3    03 

^So3 

f-.S   CD 
CD  O.P 

.S°3 

03  03 

O 

0) 

■d 

a 

o 

to   03 

°s 

G> 
■p.'O 

^3 

03 

<D 

a 

03 

a*j 

O  3 
CC  o 

si 

.  -  ho 

>  8 
"S,3 

=  a 

cog 

3 

o 

CD 
S 

_ho 

>, 

3 

3 
O 

03 

03      . 

O  N 

H 

o 

Pj 

13 
a 

cc 
o 

2 
> 

03  to' 

3  >> 

o.2 

i  T3 
!>»« 

-w  03 

G% 

03.3 

*°  >> 

23 

a! 

03  3 
03  S. 

Three  or  four  days.  Head- 
ache, backache,  great  mal- 
aise, high  fever,  and  ery- 
thematous,   evanescent 
rash. 

Fourth  day.    Successive 
stages  of  macules,  papules 
vesicles,  pustules   and 
crusts.     Confluent   or  dis- 
crete.   Papules    feel   like 
shot  under  the  skin.    Vesi- 
cles umbilicated,  with  red 
areolse. 

Minute  red   papules   on 
all  the  visible  mucosa  co- 
incident  with   the    exan- 
thema. 

■a 

3 

CO 

3 

CD 

O 

ho 
3 

3^ 

fc^  o3 

o 

High  at  first.      Falls  at 
full  eruption  to  raise  again 
on  eighth  day  with  pros- 
tration.   "Secondary 
fever." 

Laryngitis,  bronchitis, 
stomatitis,  ophthalmia, 
and  accidental   infections 
of  the  skin.    Occasionally 
nephritis. 

« 
w 
O 

£  aT 

W  J 

H 

m 
P 

03 

3 

o 
(k 

3 

03 

o 
c 

0) 

> 

0)  CO 

■a 

One  day  or  none.    Slight 
malaise,  little  or  no  fever, 
enlargement  of  post-cervi- 
cal glands. 

First  or  second  day. 
Light    red,    fine    papule's, 
first  on  face  and  confluent. 
Discrete   on    trunk   and 
limbs.    Advance  rapidly 
from  above   downwards, 
fading  behind  its  advance. 

35 

3.03 

Oo 

S°o3 

a*s 

cc  3  03 

rr-l   >."^ 

£  *  S 

J3  03 

^■B 
c? 

C3  ? 

CD- 

O 

3 
n 
o 

03 

3 

03 

S.sp 

a  >> 

"  03 

*>  u 

2^ 

3  O 

cv3 

03  g> 
ft  h 

.3 

CD 

co3 
^3 

03 

ft2 

CD  O 
CD  CD 
X  03 

03  S-, 

3 
-o 

CD  CD 
3  O 

C  >>, 

a 

cc 
W 
iJ 

CO 

«! 
H 

g, 

«■( 

►J 

o 
w 

M 
P 

03 

-a 

53 

CD 

(-    CO 

3  >•*> 
O  03 
"•-"O 

O  3 

•*-  <D 

§  >> 

a)  c3 

CO  3 

CO 

Three    to   four   days. 
Drowsiness,  headache, 
sneezing,    coryza,    cough, 
with  rising  temperature. 

Fourth  or  fifth  day.  Dark 
red  capsules,  confluent  or 
crescentric  in  arrange- 
ment,  beginnirg   on  face 
and   neck  and   spreading 
in  every  direction. 

Dark  red  or  purple  pap- 
ules on  soft  palate  one  or 
two  days   prior   to   exan- 
thema.    Koplik's  spots  on 
buccal  mucosa  two  or  three 
days  prior  to  exanthema. 

-d 

3 
03     . 

>?d 

«   CD 

3  ^ 

CD  03 
"J 
|g 

O  3 

03  ^ 
«  >> 

<S   03 

3  3 
»  c? 

ft   0) 

3-6 
•S  3 

S"cn 

0)  03 

"3  ^ 

*"3 

^S 

^  3 

.3          . 
ho3  >> 

?T3 

Catarrhal    laryngitis, 
bronchitis,     bronchopneu- 
monia, conjunctivitis,  en- 
teritis,  and    rarely    neph- 
ritis.   Tuberculosis  often. 

o  o 

.5.3 
*-  3 

«  3 

ft 

sj 

3 

a 

o 

u 

O 
u 

Ph 

o3 

a 

03 

3 

S3 

H 

w 

a 

CD 

S3 
3 

3 

3 
o 

3 

a 

03 

3 
o< 

0) 

0 

0) 
H 

3 

ctf 
CD 

ft 

a 

<D 

H 

o 
B      8 

111 

ft*  =" 

a   cc 

o 
O 

CHAPTER    XV 
THE    SPECIFIC    INFECTIOUS    DISEASES   (Continued) 

PERTUSSIS — WHOOPING-COUGH;     TUSSIS   COXVULS1VA 

Pertussis  is  a  contagious  disease  characterized  by  paroxysmal  cough, 
frequently  accompanied  by  inspiratory  whoop,  and  followed  by  ejection 
of  tough,  glairy  mucus,  and  frequently  by  vomiting. 

Although  no  age  is  exempt,  it  is  essentially  a  disease  of  childhood, 
occurring  most  frequently  in  the  first  four  years. 

Its  etiology  is  unknown,  yet  it  is  probably  of  microbic  origin  and  a 
number  of  micro-organisms  are  claimants  for  this  role.  Pertussis  is 
usually  encountered  in  epidemics,  although  sporadic  cases  are  seen.  Im- 
munity usually  follows  an  attack. 

The  only  anatomic  lesion  of  uncomplicated  pertussis  is  seen  in  an 
acute  catarrhal  condition  of  the  nasolaryngeal  and  tracheal  mucosa.  The 
laryngoscope  shows  congestion  of  the  posterior  pharyngeal  and  interary- 
tenoidal  surfaces.  Immediately  prior  to  a  paroxysm  of  coughing  a 
tenacious  plug  of  mucus  is  seen  in  the  trachea,  and  as  the  paroxysm 
terminates  with  the  extrusion  of  this  mass,  its  presence  must  be  regarded 
as  the  exciting  cause. 

The  period  of  incubation  is  indefinite,  owing  to  the  insidious  onset, 
but  it  is  probably  from  nine  to  fourteen  days. 

History  and  Symptoms. — A  child  in  apparently  good  health  is  ob- 
served to  cough  occasionally  without  distress  or  annoyance.  Physical 
examination  shows  no  lung  lesion  and  there  is  no  expectoration.  Later 
there  may  be  evidence  of  slight  nasolaryngeal  catarrh.  The  attacks  of 
coughing  become  more  frequent  and  severe  during  the  course  of  two 
or  three  weeks,  which  is  known  as  the  catarrhal  stage.  There  is  usually 
little  or  no  rise  in  temperature  and  the  true  nature  of  the  disease  may  be 
only  suspected.  A  blood  examination,  even  at  this  time,  will  show  hyper- 
leucocytosis  of  the  mononuclear  type. 

The  paroxysm  becoming  more  severe,  especially  at  night,  the  spas- 
modic stage  is  reached  and  the  clinical  diagnosis  confirmed.  The  typical 
paroxysm  consists  in  a  series  of  expulsive  efforts  of  violent  coughing 
during  which  the  lung  seems  to  be  entirely  emptied  of  air  and  the  chest 
walls  markedly  collapsed.  The  child's  face  becomes  red  and  then  purple 
and  blue  with  the  violence  of  the  attack,  and  swollen  with  the  extreme 
venous  stasis.  The  eyes  are  bulging  and  bloodshot,  and  the  respiration  is 
finally  suspended  in  complete  apnoea.  After  a  few  seconds,  during 
which  asphyxiation  seems  threatening,  a  tremendous  inspiration  occurs, 

36  561 


562  THE    SPECIFIC    INFECTIOUS    DISEASES 

accompanied  by  a  prolonged  stridulous  whoop,  caused  by  the  inrush 
of  air  over  the  vocal  cords.  The  eyes  are  suffused  and  streaming,  the 
nose  discharges  mucus,  and  the  child  clings  to  the  nearest  object  for 
support,  while  his  entire  body  is  convulsed  with  the  violent  suffoca- 
tive cough.  A  third  or  fourth  repetition  may  occur  before  relief  is  ob- 
tained in  the  expulsion  of  a  mass  of  glairy,  frothy  mucus  from  the 
throat,  frequently  accompanied  by  ejection  of  the  stomach  contents.  In 
severe  cases  the  child  shows  signs  of  complete  exhaustion,  is  livid,  bathed 
with  perspiration,  and  seems  dazed.  After  a  few  moments  of  languor 
he  resumes  his  play  as  though  nothing  had  happened. 

Inspection  of  the  child  during  this  stage  will  reveal  loss  of  flesh  and 
signs  of  innutrition,  although  the  face  may  seem  swollen.    Extravasations. 


Fig.  209.— Conjunctival  ecehymosis  and  swollen  face  in  pertussis. 

of  blood  may  occur  beneath  the  sclerotic  conjunctiva?,  in  the  subcutaneous- 
cellular  tissue  under  the  eyes,  and  in  other  portions  of  the  integument 
(Fig.  209).  Hemorrhages  may  occur  from  the  nose  and  ears  and  occa- 
sionally from  the  throat  and  stomach.  Pulmonary  emphysema  is  rarely 
absent  and  may  become  extensive.  The  emphysema  may  become  inter- 
lobular from  rupture  of  the  vesicles,  and  very  rarely  general  from  escape 
of  air  into  the  subcutaneous  areolar  tissue. 

After  two  weeks,  more  or  less,  the  stage  of  decline  supervenes  and 
all  the  symptoms  ameliorate.  A  typical  uncomplicated  case  of  pertussis 
may  occupy  from  eight  to  sixteen  weeks. 

Prognosis. — Before  the  third  year  pertussis  is  a  grave  disease  and 
exceeds  in  fatality  measles  or  scarlatina.     The  malnutrition  is  often 


WHOOPING-COUGH  563 

extreme  from  the  frequent  vomiting  of  food.  In  the  infant  fatal  con- 
vulsions may  be  induced. 

Older  children  rarely  succumb  to  pertussis,  but  the  complications 
and  sequoias  are  more  serious  and  far-reaching  than  in  any  other  disease 
of  childhood.  The  most  common  complications  are  bronchitis  and  bron- 
chopneumonia which,  in  young  infants,  prove  fatal  in  more  than  twenty- 
five  per  cent,  of  cases. 

Complications. — As  in  other  infectious  diseases  nephritis  is  common, 
the  urine  showing  albumin,  blood  and  hyaline  casts.  The  right  heart  is 
frequently  dilated,  pulmonary  emphysema  and  atelectasis  prevail,  while 
permanent  bronchiectasis  and  adenopathy  are  established  as  pathological 
bases  for  subsequent  disorders.  Few  children  pass  unscathed  through 
a  severe  attack  of  whooping-cough. 

Any  disorder  may  complicate  pertussis.  Among  the  graver  are 
bronchopneumonia,  measles,  diphtheria,  meningitis,  and  influenza.  Con- 
vulsions are  not  rare  in  infants,  probably  from  intracranial  circulatory 
disturbance,  and  meningeal  hemorrhages  may  occur  with  resultant  pa- 
ralysis, usually  hemiplegia. 

Among  the  sequelae,,  besides  the  before-mentioned  pulmonic  condi- 
tions, tuberculosis  claims  many  victims.  Myocarditis  and  otitis  media 
may  occur,  and,  in  rhachitic  children,  permanent  deformity  of  the  chest 
is  the  rule.  The  nervous  system  suffers  in  a  variety  of  ways,  many  of 
which  are  explainable  only  upon  the  theory  of  profound  intoxication. 
Loss  of  vision  and,  in  fact,  of  all  the  special  senses  have  been  reported, 
also  cases  of  Landry's  paralysis,  multiple  sclerosis,  spastic  paralysis, 
and  polyneuritides,  although  such  sequelas  are  infrequent. 

Diagnosis. — The  disease  is  recognized  by  the  convulsive  cough,  with 
or  without  whoop,  ending  in  expectoration — a  rare  occurrence  in  infants 
under  any  other  disorder — and  may  be  confirmed  by  leucocytosis  and 
the  presence  of  a  sublingual  ulcer.  In  doubtful  cases  the  negative  chest 
findings  favor  the  diagnosis  of  pertussis,  yet  it  may  co-exist  with  bron- 
chitis. The  cough  that  accompanies  bronchial  adenopathy  and  adenoid 
vegetations  of  the  nasopharynx  may  simulate  the  spasmodic  cough  of 
pertussis,  but  it  rarely  develops  to  an  extreme  degree,  and  is  unac- 
companied by  vomiting  or  expectoration,  while  a  careful  examination 
of  the  young  patient's  chest  and  pharynx  will  reveal  the  true  nature 
of  the  cause. 

Treatment. — No  specific  treatment  for  whooping-cough  is  known, 
although  a  multitude  of  remedies  have  been  exploited.  Unanimity  of 
opinion  centres  more  especially  about  the  hygiene.  Fresh  air  in  abun- 
dance is  recommended  by  all.  In  winter  or  inclement  weather  the  child 
should  be  changed  from  room  to  room  to  secure  good  ventilation  and 
freedom  from  the  effects  of  concentrated  infection.  The  bringing  to- 
gether under  one  hospital  roof  a  large  number  of  children  suffering  from 
whooping-cough  is  irrational,  and  serves  but  one  purpose, — viz.,  isola- 
tion for  the  protection  of  the  community.  Schools  should  be  protected 
by  the  prompt  exclusion  of  suspected  cases,  as  the  disease  is  contagious 


564  THE    SPECIFIC    INFECTIOUS    DISEASES 

in  every  stage.  Isolation  should  be  continued  two  weeks  after  the  cessa- 
tion of  all  symptoms. 

The  difficulties  of  nutrition  constitute  an  important  feature  in  the 
treatment  of  whooping-cough.  Feeding  upon  bland,  concentrated  food 
(milk,  beef  juice,  broths,  etc.),  immediately  after  a  paroxysm  will  secure 
the  greatest  amount  of  absorption  before  the  next  emesis. 

Cold  drinks  and  draughts  of  air  should  be  avoided  as  likely  to  induce 
coughing,  and  for  the  same  reason  all  excitement,  exertion,  and  dis- 
comfort should  be  prevented.  Drugs  which  secure  rest  and  obtund 
reflex  action  may  be  employed  in  severe  cases.  Belladonna  and  bromides 
are  still  used  with  evidence  of  some  benefit  (Formula  23).  Coal- 
tar  derivatives  which  depress  the  heart  should  be  avoided.  Digitalis 
may  be  needed  for  cardiac  support,  and  alcohol  in  some  form  may 
be  useful. 

Codeine  may  be  necessary  to  secure  sleep,  and  bromoform  still  finds 
many  advocates  where  paroxysms  are  very  severe  and  the  danger  of 
convulsions  is  imminent.  The  latter  drug  must  be  used  cautiously.  Two 
or  three  drops  to  an  infant,  and  three  or  four  drops  to  a  four-year-old 
child,  may  be  given  in  water  or  on  a  lump  of  sugar.  The  dose  may  be 
repeated  two  or  three  times  in  twenty-four  hours. 

Inhalation  of  the  vapor  of  tar,  creosote,  carbolic  acid,  or  turpentine, 
finds  favor  with  many,  and  the  vapo-cresoline  lamp  seems  to  lessen 
the  severity  of  night  paroxysms  in  some  cases.  Older  children  who  can 
take  quinine  without  gastric  disturbance  are  occasionally  benefited  by 
large  doses — five  to  ten  grains — three  or  four  times  daily. 

The  alkalinity  of  the  body  fluids  should  be  maintained.  Sodium 
bicarbonate  and  alkaline  waters  are  indicated,  and  milk  may  be  given  in 
seltzer-water. 

INFLUENZA — LA   GRIPPE;     CATARRHAL   FEVER. 

Influenza  is  an  acute  infectious  disease  characterized  by  catarrhal 
inflammation  of  the  respiratory  and  gastro-intestinal  mucosa,  profound 
nervous  disturbances,  and  extreme  debility.  It  occurs  in  both  epidemic 
and  sporadic  forms,  is  self -limited,  and  confers  no  immunity  to  subse- 
quent attacks.  Although  no  age  is  exempt,  its  occurrence  in  young  chil- 
dren is  apparently  less  frequent  than  in  adults.  Cases  have  been  re- 
ported in  the  newly  born.  The  disease  is  caused  by  a  specific  organism, 
Pfeiffer's  bacillus,  which  has  been  found  in  the  mucous  secretions  and 
occasionally  in  the  blood. 

The  period  of  incubation  is  very  brief,  frequently  only  a  few  hours, 
and  no  distinct  prodromata  are  recognized.  The  post-mortem  findings 
are  inadequate  to  explain  the  severity  of  the  symptoms,  and  consist  prin- 
cipally of  hyperemia  and  inflammation  of  the  mucous  membrane,  more 
particularly  of  the  upper  respiratory  tract,  in  addition  to  complicating 
lesions  which  are  not  constant.  The  heart  may  show  dilatation  with 
changes  in  the  myocardium,  and  rarely  acute  endocarditis.  The  spleen 
is  usually  enlarged  and  occasionally  the  kidneys  may  present  the  changes 


INFLUENZA  :.<;:> 

of  acute  nephritis.  The  blood  changes  are  peculiarly  insignificant  for 
an  infection  of  so  severe  a  type. 

Symptoms. — Among  the  many  symptoms  of  this  disease  three  groups 
stand  out  somewhat  prominently,  which  has  led  to  the  use  of  such  terms 
as  abdominal,  pulmonary,  and  nervous  forms  of  grippe.  In  children  the 
catarrhal  symptoms  usually  predominate,  the  attack  resembling  that  of 
measles  in  its  coryza,  cough,  and  mild  angina.  The  onset  is  usually 
sudden,  with  high  temperature  (which  may  follow  a  chill),  also  severe 
headache,  backache,  and  vague  muscular  pains.  Vomiting  may  be  the 
first  symptom,  accompanied  by  abdominal  cramps,  with  either  constipa- 
tion or  diarrhoea.  Great  restlessness  and  even  delirium  may  be  present, 
or  convulsions  in  infants ;   or  there  may  be  apathy,  somnolence,  or  coma. 

The  temperature  usually  shows  marked  daily  remissions  of  wide 
range,  frequently  reaching  normal  or  below  in  the  morning.  Angina  is 
rarely  absent  and  may  be  severe,  so  that  swallowing  is  difficult ;  the 
tongue  is  coated,  the  conjunctival  vessels  injected,  and  the  cough  may 
be  frequent  and  harassing,  though  examination  of  the  chest  may  yield 
only  a  few  moist  rales  and  the  pulse-respiration  ratio  show  no  dis- 
turbance. Sometimes  the  bronchial  catarrh  extends  to  the  capillary 
tubes,  or  occasionally  a  fibrinous  pneumonia  from  the  diplococcus  of 
Fraenkel  develops  with  accompanying  pleuritis.  With  convulsions  there 
may  be  stupor,  head  retraction,  cervical  rigidity,  and  symptoms  of  menin- 
gitis with  bradycardia  and  sighing  respiration. 

In  infants  the  diarrhoea  and  vomiting  may  simulate  acute  gastro- 
enteritis with  frequent  green  or  watery  stools  and  rapid  emaciation.  In 
fact,  the  degree  of  prostration  in  la  grippe  is  almost  always  remarkable 
for  the  brief  period  of  duration.  In  from  two  to  five  days  the  acute 
symptoms  usually  subside,  leaving  the  child  sometimes  with  subnormal 
temperature,  weak  and  irregular  or  very  slow  pulse.  Convalescence  is 
often  tedious  and  may  be  marked  by  recurrence  of  symptoms  upon  the 
slightest  exposure  to  cold.  Other  cases  are  so  mild  as  to  constitute 
merely  an  indisposition. 

Complications. — No  other  acute  disorder  presents  the  variety  of  com- 
plications seen  in  influenza.  It  is  owing  to  this  fact  that  a  typical  picture 
of  simple  grippe  is  rather  the  exception.  Among  the  most  common 
complications  are  pneumonia,  pleurisy,  empyema,  otitis  media,  mastoid 
disease,  pulmonary  atelectasis,  emphysema,  myocarditis,  endocarditis, 
meningitis  (cerebral  and  cerebrospinal),  follicular  tonsillitis,  herpetic 
stomatitis,  cervical  adenitis,  and  a  number  of  urticarial  and  erythema- 
tous skin  eruptions,  with  occasionally  acute  or  chronic  nephritis.  The 
most  frequent  sequelae  are  anaemia,  hypertrophied  lymph-nodes,  adenoids, 
enlarged  tonsils,  and  tuberculosis. 

Diagnosis. — A  mild,  simple  influenza  resembles  acute  catarrh  (com- 
mon cold),  and  in  the  absence  of  an  epidemic  it  is  usually  so  diagnosed. 
It  differs,  however,  in  its  greater  communicability  and  in  the  severity  of 
its  complications.  The  severer  uncomplicated  forms  may  be  diagnosed 
from  diseases  which  they  resemble — as  pneumonia — by  careful  examina- 


566  THE    SPECIFIC    INFECTIOUS    DISEASES 

tion  for  physical  signs,  by  the  sequence  and  duration  of  symptoms,  and 
by  the  absence  of  leucocytosis,  which  invariably  accompanies  fibrinous 
pneumonia.  Malarial  fever,  which  it  may  so  closely  resemble,  shows  the 
peculiar  hamiatozoon  and  yields  to  quinine.  Typhoid  fever  is  more  per- 
sistent in  its  pyrexia,  with  rose  spots,  or  Widal  reaction  in  confirmation. 
Measles  shows  Koplik's  spots  and  an  early  characteristic  rash.  Scarlet 
fever  may  be  suspected  in  the  presence  of  an  accidental  erythematous 
eruption,  but  should  be  accompanied  by  early  leucocytosis  and  later  by 
desquamation.  Pertussis  usually  shows  increase  in  lymphocytes,  and  the 
characteristic  cough  is  progressive  with  only  slight  tendency  to  pyrexia. 
In  gastro-enteritis,  grippe  may  be  suspected  if  high  temperature  and 
catarrhal  symptoms  of  the  respiratory  tract  persist.  From  meningitis 
differentiation  may  be  made  by  the  disappearance  of  cerebral  symptoms 
upon  subsidence  of  the  temperature. 

During  the  prevalence  of  epidemic  influenza  that  disease  is  usually 
credited  with  many  disturbances  to  which  it  bears  no  relation.  In  doubt- 
ful sporadic  cases  a  bacteriologic  examination  of  the  catarrhal  secretions 
may  be  necessary. 

Prognosis. — Few  children  die  of  uncomplicated  grippe,  especially 
in  its  epidemic  form.  The  many  possible  complications  afford  so  wide 
a  range  of  morbidity  as  to  leave  no  basis  upon  which  to  compute  its 
mortality.  Occasionally  the  child  is  overwhelmed  with  influenzal  tox- 
gemia  and  dies  within  a  few  days  after  the  initial  symptoms,  but  such 
occurrence  is  rare  and  death  is  usually  due  to  some  complication.  In- 
fluenza is  to  be  dreaded,  especially  for  the  predilection  of  its  convalescent 
patients  for  all  other  acute  infectious  disorders,  also  for  neurasthenia, 
weak  heart,  pulmonary  disorders,  and  tuberculosis. 

Treatment. — There  is  no  specific  treatment  for  la  grippe,  and  much 
harm  has  resulted  during  recent  epidemics  by  the  wholesale  use  of 
favorite  remedies.  The  obvious  need  for  stimulation  in  many  forms 
of  influenza  emphasizes  the  probability  of  harm  from  the  free  use  of 
the  depressing  coal-tar  derivatives  so  much  in  vogue.  It  is  possible 
that  such  therapy  must  share  the  responsibility  for  much  of  the  post- 
grippal cardiac  asthenia. 

The  child  should  be  kept  in  bed,  however  mild  the  attack,  and  iso- 
lated from  the  other  members  of  the  household.  The  same  hygiene 
should  obtain  as  for  other  infectious  and  contagious  diseases. 

Hydrotherapy,  in  all  forms  that  the  reactionary  powers  of  the  child 
will  permit,  is  indicated  for  hyperpyrexia  and  restlessness.  The  ice- 
bag  to  the  head  is  invaluable.  Bromides  are  useful  to  allay  coughs 
which,  if  severe,  may  call  also  for  heroine  or  even  paregoric  or  codeine  in 
•small  doses.  The  bowels  must  be  kept  free  with  gentle  salines,  preceded 
by  small  doses  of  calomel,  ipecac,  and  soda  (Formulas  23-25).  Gastro- 
enteric disturbances,  with  vomiting  and  diarrhoea,  may  be  met  with  bis- 
muth subgallate  and  high  enteroclysis  of  normal  salt  solution  containing 
sodium  bicarbonate,  two  and  one-half  drachms  to  the  quart  (10  Gm. 
to  1  litre). 


EPIDEMIC    PAROTITIS 


567 


The  feeding  should  be  carefully  supervised,  severe  cases  requiring 
concentrated  Liquid  diel  as  in  other  asthenic  fevers.  Stimulation  must 
not  be  forgotten,  and  ihe  hearl  may  require  digitalis  and  full  doses  of 
whiskey  or  brandy.     Strychnia  is  invaluable  during  convalescence  and 

may  be  needed  earlier  if  the  pulse  show  weakness  or  irregularity. 

EPIDEMIC   PAROTITIS — MUMPS. 

Mumps  is  a  highly  contagious  disease  of  unknown  etiology.  It  is 
rarely  seen  except  in  childhood  between  the  third  and  tenth  years; 
still,  no  age  is  exempt.  It  occurs  most  frequently  as  an  epidemic  in 
schools  and  institutions,  and  one  attack  usually  confers  immunity.  The 
disease  is  an  inflammation  of  the  parotid  glands  with  cellular  infiltra- 
tion of  the  intra-  and  peri-acinous  connective  tissue,  which  is  followed 
by  complete  resolution.  The  body  of  the  gland  is  much  enlarged,  and 
there  is  swelling  and  occlusion  of  Steno's  duct.  The  affection  is  most 
often  bilateral,  one  gland  preceding  the  other  in  the  inflammation  by  a 
few  days.  Occasionally,  however,  only  one  side  is  involved.  The  in- 
cubation period  is  from  two  to  three  weeks,  with  an  average  of  seven- 
teen days. 

Symptoms. — At  the  onset  there  are  chill,  vomiting,  fever,  anorexia 
and  malaise,  any  or  all,  with  swelling  and  tenderness  over  the  parotids 

and  behind  the  angle  of  the  jaw. 
There  may  be  drooling  in  infants, 
but  as  a  rule  the  salivary  secretion 
is  diminished  and  the  mouth  is  dry. 
Swallowing  and  attempts  at  wide 
separation  of  the  jaws  cause  pain. 
The  child  may  feel  quite  ill  for  two 
or  three  days  and  be  obliged  to 
stay  in  bed.  Usually  by  the  end  of 
a  week,  all  symptoms  have  disap- 
peared, save  some  swelling  of  the 
glands  and  a  peculiar  sensitiveness 
to  acids,  which  may  persist  for 
months  or  years. 

Complications  and  Sequela. — A 
complication  in  boys  rarely  seen  be- 
fore adolescence  is  orchitis,  which 
develops  after  the  acute  symp- 
toms have  subsided  and  may  prolong  the  case  to  a  week  or  more.  The 
testicles  may  remain  somewhat  enlarged  for  several  weeks  and  some 
atrophy  follows.  Hydrocele  is  one  of  the  rare  accompaniments.  In 
girls  the  glands  of  Bartholini,  the  ovaries,  and  the  breasts,  may  show 
swelling  and  tenderness,  which  subside  in  a  few  days  without  perma- 
nent lesions.  The  internal  ear  is  occasionally  involved,  and  deafness  is 
not  a  rare  sequel  from  affection  of  the  labyrinth  or  of  the  auditory  nerve. 
The  parotid  gland  rarely  suppurates  in  this  disease.     The  submaxillary 


Fig.  210.— Mumps. 


568  THE    SPECIFIC    INFECTIOUS    DISEASES 

lymph-nodes  frequently  share  in  the  attack  and  the  disease  is  occasionally 
confined  to  these  glands.  Mumps  may  be  associated  with  any  of  the 
infectious  diseases  of  childhood. 

Diagnosis  from  acute  adenitis  is  made  from  the  nature  of  the  onset, 
location  of  the  tumor,  and  history  of  exposure.  The  swelling  in  mumps 
develops  quickly  and  is  found  mostly  above  a  line  drawn  parallel  with 
the  lower  border  of  the  jaw.  The  centre  of  the  tumescence  is  marked 
also  by  the  ear  lobe,  which  is  pushed  outward  by  the  swelling  (Fig.  210). 

The  prognosis  in  parotitis  is  good. 

Treatment. — Mild  laxatives  and  protection  of  the  glands  by  a  flannel 
passed  under  the  chin  and  secured  on  top  of  the  head  are  all  that  are 
required.  The  child  should  be  isolated  for  three  weeks  to  prevent  the 
spread  of  the  infection. 

DIPHTHERIA. 

Klebs-Loeffler  diphtheria  is  a  highly  infectious  and  communicable 
disease,  caused  by  the  diphtheria  bacillus,  first  discovered  by  Klebs  in 
1883.  The  disease  manifests  itself  by  local  processes  caused  by  the 
growth  of  the  micro-organism,  by  constitutional  disturbances  due  to 
absorption  of  their  toxins,  and  by  complications  and  sequela?  which  are 
characteristic. 

Etiology  and  Mode  of  Infection. — No  age  is  exempt,  yet  diphtheria 
occurs  with  the  greatest  frequency  from  the  second  to  the  sixth  year, 
and  attacks  both  the  weak  and  strong.  A  catarrhal  condition  of  the 
throat  predisposes  to  the  infection,  also  adenoids  of  the  pharyngeal  vault, 
in  the  sulci  of  which  the  Klebs-Loeffler  bacilli  find  an  ideal  cultural 
condition.  One  attack  does  not  grant  immunity  except  for  a  limited 
period,  but,  on  the  contrary,  rather  predisposes  to  subsequent  infection 
from  the  resultant  disordered  condition  of  the  affected  mucosa.  The 
infectious  agent  is  always  the  Klebs-Loeffler  bacillus,  from  other  diph- 
theritic lesions.  Domestic  animals — such  as  poultry,  cats,  dogs,  rabbits, 
or  cows — are  all  known  to  suffer  from  the  disease.  The  bacilli  gain 
entrance  through  some  abrasion  or  fissure  in  the  mucous  membrane  or 
skin.  The  period  of  incubation  is  not  known,  as  the  organisms  may 
remain  indefinitely  upon  the  mucosa  until  some  catarrhal  process  or 
other  solution  of  continuity  furnishes  favorable  conditions  for  their 
pathogenic  activity.  From  a  few  hours  to  several  weeks  may  intervene 
between  exposure  to  infection  and  the  development  of  symptoms. 

No  doubt  much  depends  upon  the  virulence  of  the  invading  organ- 
ism as  well  as  upon  the  resistance  of  the  child,  as  patients  infected 
from  the  same  source  differ  widely  in  their  reaction  to  the  poison.  So, 
also,  different  epidemics  show  marked  differences  in  their  severity 
and  fatality. 

The  bacillus  is  found  in  the  secretions  from  the  affected  surfaces, 
as  the  nasal  discharge,  sputum,  etc.,  but  not  in  the  urine  or  fa?ces. 
The  organisms  are  very  tenacious  of  life  and  may  retain  their  virulence 
for  weeks  in  dried  secretion  or  shreds  of  membrane.  They  may  be 
conveyed  long  distances  on  clothing,  toys,  books,  or  transferred  directly 


DIPHTHERIA  569 

by  contact  with  the  patient,  or  by  using  spoon,  napkin,  or  dishes  from 
the  sick-room.  Often  the  bacilli  are  found  in  the  mouths  of  healthy 
persons  who  have  been  aboul  a  patient,  and  doctors  or  nurses  quite  fre- 
quently convey  the  infection  without  themselves  feeling  its  influence. 
In  the  same  way  pupils  and  teachers  coming  from  homes  of  patients 
spread  the  epidemic  through  schools  and  communities. 

Pathology. — The  characteristic  Local  lesion  is  a  pseudomembraneous 
formation  on  the  mucous  membrane  or  denuded  skin.  The  most  common 
lesions  are  found  in  the  throat,  nasopharynx,  nares,  and  larynx,  though 
it  may  extend  to  the  trachea,  bronchi,  Eustachian  tube,  middle  ear, 
accessory  nasal  sinuses,  buccal  surfaces,  oesophagus,  or  stomach.  The 
membrane  may  be  found  upon  the  palpebral  conjunctiva,  lips,  vulva, 
or  about  the  corners  of  the  mouth,  behind  the  ear,  and  at  the  umbilicus. 
Diphtheritic  pseudomembrane  is  made  up  of  degenerated  epithelium, 
debris,  pus  cells,  cocci,  blood  cells,  round  cells,  and  diphtheria  bacilli 
enmeshed  in  a  stratum  of  fibrinous  exudate.  It  varies  greatly  in  its 
components  as  to  thickness,  color,  and  consistency,  from  a  mucous,  ca- 
tarrhal coating,  which  may  be  wiped  off,  to  a  dense  exudate  which  adheres 
closely  to  the  underlying  membrane  with  which  it  is  structurally  in- 
corporated. The  latter  form  is  most  commonly  associated  with  squamous 
epithelium.  From  the  columnar  variety  it  is  more  readily  detachable  (Fig. 
145).  Other  organisms,  many  of  which  are  pathogenic,  are  invariably 
associated  with  this  local  process,  foremost  among  which  are  the  strepto-, 
staphylo-,  and  pneumococcus,  and  the  colon  bacillus,  whose  toxic  products 
by  symbiotic  action  intensify  the  systemic  disturbance.  In  fact,  the 
severity  of  the  disease  depends  so  largely  upon  the  activity  of  these 
associated  bacterial  toxins  that  "mixed  infection"  greatly  increases  the 
gravity  of  the  prognosis. 

Aside  from  the  local  lesions  of  the  infected  mucosa,  changes  occur 
in  other  tissues  and  organs,  not  from  the  bacilli  themselves  but  from 
their  absorbed  toxins.  There  is  adenitis  and  sometimes  breaking  down 
of  the  cervical,  bronchial,  and  mesenteric  lymph-nodes ;  cloudy  swelling 
and  degeneration  occur  in  the  kidneys  and  frequently  severe  acute 
inflammation;  in  the  liver  there  is  cell  necrosis  and  hemorrhages  be- 
neath the  capsule;  the  heart  muscle  is  softened  and  shows 'areas  of 
fatty  changes;  the  spleen  is  congested  and  may  be  degenerated,  and 
the  lungs  may  show  diphtheritic  bronchitis,  bronchopneumonia  or,  with 
the  strepto-  and  pneumococcus,  develop  a  true  fibrinous  pneumonia. 
The  blood  shows  some  loss  of  hemoglobin  and  slight  decrease  in  the 
erythrocytes;  early  leucocytosis  is  practically  constant  and  corresponds 
in  a  general  way  with  the  severity  of  the  symptoms,  although  not  neces- 
sarily with  the  extent  of  the  primary  lesion.  Rapid  increase  in  toxaemia 
at  times  overwhelms  phagocytic  activity  and  Leucopenia  results.  The 
nerve  tissues  are  especially  vulnerable  and  rarely  escape  degenerative 
changes.  Even  in  mild  attacks  the  nerve-fibres  show  degeneration  which 
may  be  so  extensive  as  totally  to  destroy  their  function. 

Symptoms. — The  prodromata  are  rarely  recognized.     If  on  the  alert 


570  THE    SPECIFIC    INFECTIOUS    DISEASES 

for  symptoms  after  a  known  exposure,  a  slight  chill  may  be  noted  with 
some  malaise  and  the  f  aucial  mucosa  may  show  hyperemia.  Occasionally 
general  indisposition  with  fever,  headache,  vomiting,  anorexia,  or  cough, 
with  coated  tongue,  constipation,  or  diarrhoea,  may  exist  for  several  days. 

With  such  symptoms  any  one  of  a  variety  of  diagnoses  may  be  made, 
and  correctly,  too;  for  in  many  instances  the  diphtherial  infection  is 
but  accidentally  engrafted  upon  some  other  disorder  which  increases 
the  child's  vulnerability.  On  the  other  hand,  the  onset  may  be  abrupt, 
in  the  midst  of  perfect  health,  with  chill,  fever,  or  vomiting.  The  initial 
temperature  is  usually  not  high,  but  may  reach  104°  F.  (40°  C.)  the 
first  night  and  in  infants  convulsions  may  rarely  occur.  The  pulse  is 
usually  rapid.  Unless  a  thorough  examination  be  made  the  throat  lesion 
may  escape  detection.  In  some  cases  angina,  with  a  feeling  of  rawness 
and  painful  deglutition,  is  the  first  indication.  Inspection  shows  faucial 
hyperemia  with  swelling  of  the  tonsils,  one  or  both  of  which  may  show 
a  whitish  speck  which  resembles  lacunar  tonsillitis.  In  fact,  the  clinical 
differentiation  is  often  impossible  and  the  two  may  be  coincident,  or 
more  frequently  diphtheritic  infection  complicates  a  pre-existing  benign 
angina,  so  that  negative  findings,  both  clinical  and  cultural,  need  embar- 
rass no  practitioner  if  later  the  case  develop  true  diphtheria.  Usually 
in  a  few  hours  the  whitish  speck  declares  its  true  character  by  extending 
rapidly  over  the  surface,  and  appears  upon  the  opposite  tonsil  or  upon 
the  adjacent  face  of  the  uvula  and  connecting  palatal  arch.  The  exudate 
may  be  seen  upon  the  wall  of  the  pharynx  and  edges  of  the  epiglottis, 
and  by  the  second,  third,  or  fourth  day  the  nasal  voice  and  discharge 
from  the  nostrils  indicate  invasion  of  that  area  through  the  posterior 
nares.  The  breath  is  fetid,  the  throat  is  swollen,  the  tongue  coated, 
and  the  cervical  and  submaxillary  lymph  nodes  are  enlarged.  In  severe 
infection  tumefaction  extends  from  the  angle  of  the  jaw  almost  to  the 
clavicle,  owing  to  infiltration  of  the  periglandular  cellular  tissue,  and 
abscess  formation  seems  imminent,  yet  as  a  rule  resolution  occurs  with- 
out suppuration.  In  mixed  infection  with  the  streptococcus,  suppura- 
tion and  necrosis  may  occur  with  occasionally  extensive  sloughing  of 
tissues.  The  voice  is  thick,  the  face  gray,  and  the  pulse  weak  and  rapid. 
The  membrane,  at  first  white  and  thin,  becomes  gray  and  thick  with  well 
denned,  thick,  rounded  edges,  and  looks  as  though  it  might  be  lifted 
entire.  Later  it  is  brownish-green,  pultaceous  and  necrotic  in  appear- 
ance. The  temperature  is  rarely  high,  considering  the  gravity  of  the 
infection,  and  may  not  exceed  102°  F.  (39°  C).  Frequently  a  fairly 
severe  case  may  run  its  course  with  temperature  below  101°  F.  (38.5° 
C).  However,  the  temperature  is  erratic  and  may  be  high  at  the  onset. 
This  is  especially  true  in  infants  and  young  children. 

Albumin  usually  appears  in  the  urine  by  the  second  or  third  day  and 
in  some  cases  it  may  increase  rapidly.  Casts  are  found,  both  granular 
and  hyaline;  also  blood  in  small  quantities.  Occasionally  symptoms 
develop  showing  that  the  larynx  has  been  invaded.  (See  Membranous 
Laryngitis.) 


DIPHTHEEIA  571 

The  nervous  symptoms  are  quite  variable.  In  severe  toxaemia,  espe- 
cially in  mixed  infection,  the  sensorium  is  overwhelmed.  The  child 
lies  in  a  stupor  or  lethargy  will)  pallid,  swollen  face.  The  head  is 
retracted  to  relieve  the  pressure  upon  the  larynx   from   infiltration  of 

the  cervical  and  pharyngeal  1  issues;  a  thin,  mucopurulent  secreiiun, 
sometimes  bloody,  exudes  from  the  nose,  excoriating  the  lips,  which 
are  black  and  crusted;  while  the  dry,  black  tongue  is  fissured  and  foul 
from  desiccated  epithelium  and  secretions.  The  noisy  oral  respiration 
and  high-pitched,  querulous  voice,  the  fetid  odor,  and  profound  pros- 
tration, present  a  picture  never  to  be  forgotten.  Other  cases,  although 
severe,  may  show  no  mental  disturbance  save  irritability,  and  the  mind 
is  often  clear  till  near-  the  end. 

Diphtheria  presents  many  grades  of  severity,  but  for  convenience 
of  description  five  varieties  may  be  mentioned, — first,  severe  extending 
diphtheria,  described  above;  second,  mild  tonsillar  diphtheria;  third, 
nasal  diphtheria ;  fourth,  laryngeal  diphtheria,  and  fifth,  catarrhal 
diphtheria,  or  diphtheria  sin<   membrana. 

The  second  variety  may  show  only  a  limited  exudate  on  one  or  both 
tonsils.  Epidemics  occur  in  which  this  form  predominates.  The  diph- 
theritic membrane  shows  no  tendency  to  extend  beyond  the  inner  surface 
of  the  tonsils,  and  the  constitutional  symptoms  are  not  marked,  older 
children  being  kept  in  the  house  with  difficulty.  Without  careful  routine 
examination  the  local  lesion  might  have  been  overlooked.  At  other 
times  there  is  some  soreness  and  tenderness  upon  swallowing  that  first 
attracts  attention.  The  cervical  glands  are  but  slightly  involved.  In- 
fants at  the  breast  sometimes  refuse  to  take  the  nipple,  thus  leading 
to  discovery  of  the  angina. 

The  third,  or  nasal,  variety  may  complicate  the  anginal,  or  it  may 
begin  de  novo  in  the  nasal  cavity  and  remain  confined  to  that  area. 
This  form  is  most  frequently  seen  in  infants  and  simulates  chronic 
rhinitis  or  syphilitic  snuffles.  The  constitutional  symptoms  may  be  mild 
and  attributed  to  a  simple  nasal  catarrh.  A  sanious  or  ichorous  dis- 
charge from  the  nostrils  should  always  suggest  its  presence,  although 
frequently  no  membrane  may  be  seen.  The  infection  may  extend  to 
adjacent  areas  or  to  the  lungs,  or  appear  in  other  members  of  the  house- 
hold as  a  severe  faucial  diphtheria.  In  this  form  the  child  may  harbor 
bacilli  in  the  accessory  nasal  sinuses  for  months  and  prove  a  very  maga- 
zine of  diphtheritic  infection. 

The  fourth,  or  laryngeal,  form  is  also  seen  most  frequently  in  infants, 
although  it  may  complicate  the  other  forms.  Frequently  the  first  inti- 
mation is  the  sudden  development  of  croup,  and  the  false  membrane 
may  be  confined  to  the  larynx.  Occasionally  its  true  nature  is  revealed 
by  extension  of  the  exudate  upward  or  its  development  in  other  members 
of  the  family.  Every  case  of  croup  should  be  held  suspicious  until  the 
cessation  of  all  symptoms. 

The  fifth  variety  cannot  be  distinguished  clinically  from  other  forms 
of  catarrhal  or  amygdalar  tonsillitis.     No  membrane  appears,  the  throat 


572  THE    SPECIFIC    INFECTIOUS    DISEASES 

may  be  quite  sensitive,  and  adjacent  glands  may  show  moderate  enlarge- 
ment. The  prevalence  of  epidemic  diphtheria,  or  its  occurrence  in  other 
members  of  the  family,  should  suggest  its  true  character. 

Diagnosis. — Not  all  membranous  lesions  of  the  fauces  and  upper 
respiratory  tract  are  Klebs-Loeffler  diphtheria.  Occasionally  acute  le- 
sions without  visible  membrane  show  that  organism  to  be  the  etiologic 
agent.  A  wise  conservatism  would  regard  all  acute  nasal,  pharyngeal, 
faucial  and  laryngeal  inflammations  as  suspicious  until  negatived  by  re- 
peated cultural  and  clinical  tests.  This  is  especially  true  if  diphtheria 
be  known  to  exist  in  the  community.  A  case  showing  well-marked  diph- 
theritic membrane  presents  few  diagnostic  difficulties.  In  doubtful 
cases  little  harm  follows  an  error  in  favor  of  diphtheria.  The  conse- 
quences of  error  in  the  other  direction  are  incalculable,  from  which  the 
physician  may  not  escape  responsibility.  Smears  and  cultures  should 
be  made  in  every  doubtful  case  and  repeated  until  the  non-existence  of 
Klebs-Loeffler  bacillus  is  established.  Every  form  of  diphtheria,  even  the 
mildest,  may  furnish  infection  of  the  most  virulent  type.  A  number  of 
extensive  epidemics  have  been  traced  to  a  single  mild,  unsuspected  case. 

The  contention  is  still  on  regarding  the  status  of  non-infectious  forms 
and  pseudodiphtheritic  bacilli.  For  all  practical  purposes  they  may  be 
treated  as  Klebs-Loeffler  diphtheria,  since  a  number  of  grave  mistakes 
have  resulted  from  overrefinement  in  differentiation.  All  forms  of  diph- 
theritic membrane  upon  wounds  or  abrasions  of  external  parts  should  be 
regarded  as  true  diphtheria — as  indeed  they  usually  are — and  they  have 
been  known  to  induce  infection  of  a  severe  type  in  others.  (For  Con- 
junctival Diphtheria,  see  chapter  on  the  Eye.) 

Prognosis. — Death  in  diphtheria  may  be  due  to  toxaemia  in  the 
second  or  third  day  of  the  attack,  or  after  a  severe  mixed  infection  in 
the  second  week,  or  from  asphyxiation  due  to  laryngeal  stenosis,  or  at 
any  time  during  the  disease,  whether  mild  or  severe,  from  heart  failure 
or  from  cardiac  thrombosis.  Three  causes  operate  to  render  the  stability 
of  the  heart  extremely  precarious  under  the  action  of  diphtheritic  toxae- 
mia,— viz.,  the  myocardial  changes  resulting  in  asthenia  of  the  heart 
muscle,  the  changes  in  the  blood  and  in  the  vascular  intima,  with  the 
danger  of  thrombosis,  and  the  degeneration  of  nerve  tissue  (toxic  neu- 
ritis), with  paralysis  of  the  pneumogastric  or  cardiac  nerves.  The  fatal 
syncope  may  occur  without  warning  either  during  the  attack  or  after 
convalescence  as  a  result  of  some  trifling  exertion  or  excitement.  In  the 
latter  case  it  is  attributed  to  the  postdiphtheritic  paralysis.  In  some 
instances  the  fatal  syncope  is  preceded  by  vomiting,  abdominal  pain,  and 
weak,  irregular  pulse,  gallop  rhythm,  anxious  facies,  apathy,  and  cya- 
nosis. In  the  general  postdiphtheritic  paralysis  death  may  occur  through 
respiratory  failure  from  paralysis  of  the  diaphragm. 

The  prognosis  of  diphtheria  depends  so  largely  upon  the  age  of  the 
patient,  the  virulence  of  the  infection,  the  location  of  the  lesion  and  the 
complications,  also  the  promptness  and  method  of  treatment,  that  no  tabu- 
lation of  any  value  can  be  made.    Infants  succumb  quickly  and  statistics, 


DIPIITIIKKIA  573 

including  many  thousand  cases,  give  ;i  mortality  of  over  fifty  per  cent. 
After  the  fifth  year  ten  per  cent,  would  be  ;i  high  estimate.  All  data 
prior  to  the  advent  of  antitoxin  are  rendered  worthless  as  to  their  prog- 
nostic value  by  the  remarkable  decrease  in  mortality  under  that  treat- 
ment. The  disease,  though  still  grave,  has  lost  much  of  its  terror  during 
the  past  decade  for  the  above  reason. 

Complications  and  sequela  include  bronchopneumonia,  pleuritis, 
otitis  media,  gastro-enteritis,  suppuration  of  the  cervical  glands,  retro- 
pharyngeal abscess,  postnasal  adenoids,  myocarditis,  and  cardiac  paraly- 
sis, either  during  the  disease  or  as  a  sequel,  also  acute  nephritis  and 
rarely  pericarditis  and  endocarditis.  Cerebral  complications  may  cause 
convulsions,  aphasia,  or  hemiplegia.  If  peripheral,  monoplegia,  anaes- 
thesia, or  gangrene  of  a  part  may  result. 

Sequela?  most  characteristic  are  the  postdiphtheritic  neuritides,  both 
peripheral  and  spinal,  the  latter  involving  the  multipolar  ganglion  cells 
of  the  anterior  columns,  and  the  former  representing  many  forms  of 
multiple  neuritis.  The  most  common  form  of  postdiphtheritic  neuritis 
is  seen  in  the  paresis  of  the  levator  palati  which  allows  regurgitation  of 
fluid  through  the  nose  upon  attempting  to  swallow.  This  may  occur 
during  the  attack,  if  prolonged,  but  usually  appears  as  a  sequel  and  has 
led  to  a  diagnosis  of  diphtheria  in  many  previously  unsuspected  cases. 
In  the  same  manner  paresis  of  the  epiglottis  and  the  arytenoidei  may 
allow  entrance  of  food  and  cocci  into  the  trachea  and  cause  aspiration 
pneumonia.  After  severe  cases  there  is  always  profound  anaemia  with 
extreme  myasthenia,  and  even  a  mild  attack  causes  muscular  weakness 
to  a  remarkable  degree. 

Treatment. — The  treatment  of  diphtheria  is  special,  local,  and  pro- 
phylactic. The  past  decade  has  developed  the  antitoxin  treatment,  so 
that  to-day  it  is  justly  regarded  as  a  specific.  Several  firms  now  produce 
a  diphtheritic  antitoxin  which  is  of  guaranteed  potency  and  is  both  safe 
and  reliable.  As  the  efficiency  of  antitoxin  depends  upon  its  early 
administration  it  should  he  injected  upon  the  first  indication  of  diph- 
theria. Mindful  of  the  possible  serious  complications  and  sequelae  of 
even  a  mild  diphtheria,  the  physician  will  not  defer  unnecessarily  for 
even  an  hour  the  use  of  this  agent.  In  suspicious  cases  the  antitoxin 
should  take  precedence  of  the  bacteriologic  diagnosis,  for  it  should  be 
borne  in  mind  that  antitoxin  will  not  repair  the  damage  to  tissues  and 
organs  already  sustained,  but  will  only  combat  the  toxins  and  thus  pre- 
vent further  injury.  The  deduction  is  obvious.  Stop  the  process  before 
extensive  degenerative  changes  occur.  With  a  surgically  clean  hypo- 
dermic needle  (leading  manufacturers  now  furnish  a  sterile  injecting 
apparatus  with  each  package  of  antitoxin  so  that  the  pocket  syringe  is 
practically  obsolete  for  this  purpose)  the  fluid  should  be  injected  slowly 
under  the  skin  between  the  scapulae,  upon  the  abdomen,  or  upon  the 
outer  aspect  of  the  thigh,  the  part  having  first  been  rendered  aseptic 
as  for  an  operation.  The  site  of  the  puncture  after  withdrawal  of  the 
needle  should  be  covered  with  a  dry,  aseptic  dressing.      For  a  child 


574  THE    SPECIFIC    INFECTIOUS    DISEASES 

under  two  years  3000  units,  at  least,  should  be  injected.  Older  children 
should  receive  proportionately  larger  doses — from  4000  to  6000  units — 
and  in  severe  or  advanced  cases  8000  units  should  be  used.  If  signs  of 
improvement  do  not  follow  in  eight  hours,  another  dose  should  be 
administered  and  this  repeated  every  eight  hours  until  signs  of  improve- 
ment are  positive,  when  smaller  doses  may  be  used.  In  very  severe  cases 
the  antitoxin  should  be  given  oftener  and  in  larger  doses.  The  limited 
space  will  not  allow  a  further  discussion  of  this  subject.  Statistics  are 
ample  and  conclusive  concerning  the  value  of  antitoxin  in  diphtheria  if 
administered  early,  and  frequently  repeated  in  large  doses,  with  strict 
aseptic  precautions. 

Local  treatment  should  not  be  neglected.  Gargles,  sprays,  swabbings, 
and  irrigation  may  be  employed  (if  they  do  not  excite  or  fatigue  the 
child)  to  keep  the  affected  surfaces  and  their  adjacent  areas  as  clean 
as  possible,  for  it  is  to  be  remembered  that  associated  organisms,  against 
which  the  antitoxin  is  powerless,  are  in  full  operation,  with  pathologic 
results  hardly  inferior  to  those  of  the  Klebs-Loeffler  bacilli.  Hydrogen 
peroxide  and  water  (1  :  5)  ;  Seller's  solution  (Formula  11)  ;  solution  of 
boric  acid  (five  per  cent.)  ;  potassium  permanganate  solution  (1  :  5000), 
are  all  available  for  this  purpose.  The  nose  should  be  irrigated  as  well 
as  the  throat,  for  which  normal  salt  solution  answers  quite  well,  as  the 
purpose  is  largely  to  clean  out  the  fossas  and  flush  the  nasopharynx.  The 
ice-bag  to  the  neck  is  the  only  external  application  indicated.  Hot 
poultices  are  contraindicated. 

The  tendency  to  cardiac  myasthenia  calls  for  the  early  use  of  strych- 
nia in  full  doses.  The  toleration  for  this  drug  in  diphtheria  is  out  of  all 
proportion  to  the  amounts  usually  given.  A  four-year-old  child  may 
need  one-fortieth  grain  (0.0016  Gm.)  hypodermically  every  three  hours 
for  a  number  of  days  or  weeks  to  sustain  the  pulse.  Whiskey  may  be 
given  to  combat  the  toxasmia.  A  child  of  two  years  will  easily  take  one- 
half  to  one  and  one-half  ounces  (15-45  C.c.)  daily,  in  divided  doses 
properly  diluted. 

The  possibility  of  cardiac  syncope  contraindicates  measures  which 
tax  the  child's  endurance  or  arouses  excitement,  so  that  a  tactful,  ex- 
perienced nurse  is  indispensable. 

An  irregular  pulse  not  controlled  by  strychnia  may  require  digitalis 
in  addition,  if  well  borne  by  the  stomach,  or  digitaline  hypodermically. 
Aromatic  spirits  of  ammonia  may  serve  a  purpose  in  extreme  cardiac 
weakness,  but  most  reliable  in  the  fluttering  pulse  of  threatened  syncope 
is  morphine,  hypodermically,  in  doses  sufficient  to. maintain  a  continuous 
narcotic  effect. 

Upon  the  appearance  of  diphtheria  the  members  of  the  household,' 
and  all  who  have  come  in  contact  with  the  patient  or  any  probable  source 
of  infection,  should  receive  immunizing  doses  of  antitoxin, — 300  units 
for  a  baby;  500  units  for  a  child  of  five  years,  and  500  to  1000  units 
for  older  children. 

When  diphtheria  is  known  to  exist  in  a  community  or  school  it  is 


DIPHTHERIA  575 

desirable  to  give  immunizing  in.jeeiions  to  all  the  children  of  thai  com- 
munity. Although  the  period  of  immunity  is  not  definitely  known,  if 
it  continue  for  only  six  weeks,  an  epidemic  may  be  averted  from  want 
of  susceptible  material  for  propagation  of  the  infection. 

It  is  the  duty  of  health  boards  to  attend  to  this  matter  which,  if 
thoroughly  done,  diphtheria,  like  variola,  would  be  eliminated  from  the 
perils  of  childhood.  Physicians  and  nurses  who  pass  in  and  out  should, 
upon  entrance  to  the  sick-room,  wear  a  gown  of  wash  material  to  protect 
the  clothing,  a  simple  cap  also  covering  the  hair,  both  to  be  left  hanging 
by  the  door.  Absolute  cleanliness  in  the  care  of  the  hands  and  nails  by 
use  of  soap,  brush,  and  antiseptic  solutions,  must  be  observed. 

The  effects  of  antitoxin  are  usually  seen  within  ten  to  twenty-four 
hours,  in  a  general  amelioration  of  all  the  symptoms.  The  extension  of 
the  pseudomembrane  is  arrested  and  its  edges  loosen  a  little  and  finally 
large  masses  come  away.  At  times  the  exudate  seems  to  melt  away  under 
the  action  of  the  antitoxin.  In  laryngeal  diphtheria  the  greatest  benefit 
is  seen,  cases  that  were  formerly  regarded  as  hopeless  recovering  with- 
out even  the  use  of  the  tube. 

Two  effects  of  antitoxin  should  be  mentioned  here  so  that  the  in- 
experienced be  not  taken  unawares.  The  first  is  seen  after  its  adminis- 
tration in  laryngeal  diphtheria.  If  intubation  be  deemed  advisable  (it 
rarely  is),  the  action  of  antitoxin  in  loosening  the  membrane  should  be 
remembered,  since  the  tube  is  likely  to  double  down  the  loose  edges  of 
the  membrane  and  push  it  ahead,  with  danger  of  occlusion  of  its  lumen. 
The  other  is  an  eruption  of  several  varieties,  some  of  which  develop 
within  a  few  hours,  others  not  until  one  or  two  weeks  after  the  injection. 
The  eruption  is  benign  and  requires  no  treatment. 

The  care  of  the  patient  requires  the  application  of  the  best-known 
hygiene, — a  large  sunny  room  with  free  access  of  air  (sunlight  and  air 
are  the  great  foes  to  the  bacilli  diphtherias).  All  carpets,  rugs,  uphol- 
stery, and  tapestry  should  be  removed  and  the  child  placed  under  strict 
quarantine.  The  food  should  be  liquid,  concentrated  for  older  children, 
and,  if  necessary,  partially  predigested.  The  bowels  should  be  kept  in 
order  by  appropriate  laxatives.  All  secretions  should  be  received  on  old 
cloths,  which  must  be  burned.  Feeding  utensils  should  not  leave  the 
sick-room,  and  a  plentiful  supply  of  carbolic  acid  (five  per  cent,  solu- 
tion) should  receive  everything  that  comes  in  contact  with  the  patient. 
A  nursing  baby  should  be  taken  from  the  nipple  and  fed  on  the  pumped 
breast  milk. 

Convalescence  should  be  carefully  guarded  because  of  the  danger  of 
postdiphtheritic  neuritis  with  syncope.  Elixir  of  iron,  quinine,  and 
strychnine  is  indicated  as  a  restorative  tonic  at  this  time.  The  child 
should  be  considered  infectious  until  three  successive  cultures,  taken  at 
twenty-four-hour  intervals,  show  negative  results.  The  nasal  cavity  is 
the  last  place  to  harbor  the  bacilli  and  should  receive  thorough  antiseptic 
irrigation  three  or  four  times  daily.  After  recovery  a  most  thorough 
antiseptic  cleaning  of  patient  and  room  is  necessary. 


576  THE    SPECIFIC    INFECTIOUS    DISEASES 

DIPHTHEROID — PSEUDODIPHTHERIA. 

Pseudomembranes  may  develop  in  which  the  Klebs-Loeffler  bacillus 
plays  no  part.  They  are  a  frequent  accompaniment  of  acute  infectious 
diseases  with  angina,  especially  scarlatina,  and  may  develop  upon  any 
inflamed  mucous  membrane. 

The  cause  of  this  membrane  formation  may  be  the  streptococcus, 
staphylococcus,  pneumococcus,  gonococcus,  or  the  bacterium  coli.  Since 
these  membranous  formations  may  not  be  distinguished  clinically  from 
those  due  to  the  bacillus  diphtheria?,  they  have  been  termed  diphtheroid. 
Aside  from  the  bacteria  above  mentioned,  an  organism  has  been  isolated 
in  pure  culture  which  resembles  morphologically  and  shows  similar 
staining  properties  to  the  Klebs-Loeffler  bacillus,  and  may  be  differenti- 
ated only  by  its  effects  shown  in  animal  inoculation.  In  a  general  way 
this  organism  is  very  aptly  designated  "diphtheroid"  bacillus  (pseudo- 
diphtheritic  bacillus). 

Diphtheroid  may  simulate  true  diphtheria  in  every  respect  save  in 
the  intensity  of  its  toxaemia  and  in  the  gravity  of  its  sequelae.  Of  the 
latter  it  has  few  worthy  of  mention. 

The  prognosis  is  good  as  regards  diphtheroid  per  se,  but  as  a  com- 
plication of  other  acute  infections  it  may  increase  the  gravity.  It  is 
chiefly  of  importance  in  complicating  the  diagnosis  of  diphtheria,  since 
at  times  the  bacteriologic  differentiation  requires  the  most  refined 
laboratory  technique. 

Treatment  of  diphtheroid  is  symptomatic,  with  proper  hygiene  and 
sanitary  care  of  the  affected  mucosa.  As  stated  under  treatment  of 
diphtheria,  every  doubtful  or  even  suspicious  case  should  receive  anti- 
toxin. 

INTUBATION   OP   THE  LARYNX.  ' 

The  old  controversy  in  regard  to  the  relative  efficacy  of  tracheotomy 
and  intubation  in  diphtheritic  laryngeal  stenosis  has  been  settled  by 
wide  experience  in  favor  of  the  latter  in  a  large  majority  of  cases.  The 
facts  supportive  of  this  conclusion  need  no  further  elucidation.  The 
hesitancy  to  intube,  on  the  part  of  the  practitioner,  is  largely  a  matter 
of  unf  amiliarity  with  its  technique.  Many  physicians  who  readily  under- 
take a  laparotomy  and  other  capital  operations  shrink  from  the  intro- 
duction of  a  laryngeal  tube.  How  many  lives  have  been  lost  through 
this  hesitancy  it  is  useless  to  conjecture.  Thanks  to  the  efficiency  of 
early  antitoxin  the  need  for  intubation  is  rapidly  lessening. 

The  operation  is  so  simple  and  so  important  that  a  technical  famili- 
arity should  belong  to  the  equipment  of  every  practitioner.  This 
familiarity  may  be  secured  by  a  very  little  practice  upon  the  child 
cadaver.  With  his  steady  nerve,  an  O'Dwyer  intubation  set,  and  two 
intelligent  assistants  (not  the  parents),  he  is  ready  to  proceed.  The 
proper  tube  for  size  rather  than  for  age  of  child  having  been  selected 
and  threaded  with  ample  loop  of  stout  ligature  silk,  the  obturator  is 
screwed   to   the   introducer   and   tested   to   see   if   the   detacher   works 


INTUBATION    OF    THE    LARYNX  577 

properly.  The  child,  firmly  wrapped  in  a  blanket,  arms  included,  is  held 
by  a  nurse  sitting  so  that  the  child's  right  car  is  opposite  the  nurse's 
left  jaw.  The  tongue  is  depressed,  the  gag  inserted  behind  the  left 
molars,  and  opened  widely  where  it  is  steadied  by  the  Left  hand  of  the 
second  assistant,  who  stands  behind  the  nurse  fixing  the  child's  head 
with  both  hands.  Only  very  slight  extension  of  the  child's  neck  is 
advisable,  as  it  deranges  the  relations  of  the  Held  of  operation.  The 
physician,  standing  or  sitting,  holds  the  introducer  (tube  attached) 
lightly  in  his  right  hand,  thumb  resting  upon  the  slide,  and  index-finger 
in  the  ring  or  in  front  of  the  trigger  below.  The  thread  is  passed  back  be- 
tween two  fingers.  The  left  forefinger  is  introduced  into  the  right  angle 
of  the  child's  mouth,  its  tip  carried  back  so  as  to  engage  the  epiglottis, 
which  is  pressed  forwards  and  a  little  to  the  child 's  right,  and  there  held 
against  the  dorsum  of  the  tongue.  The  tube  is  then  advanced  in  the 
median  line  following  the  left  finger  as  a  guide  to  its  tip.  The  flat  palate 
of  the  child  makes  it  necessary  to  hold  the  handle  of  the  introducer  at 
first  parallel  with  the  child 's  sternum ;  when  the  tip  of  the  tube  reaches 
the  epiglottis  the  handle  is  raised  sharply,  describing  a  quadrant ;  the 
tip  of  the  tube  having  now  passed  the  tip  of  the  finger  is  made  to  hug 
the  posterior  surface  of  the  epiglottis,  and  with  slight  further  elevation 
of  the  handle  and  gentle  depression  of  the  tube  it  enters  the  chink  half 
its  length,  where  it  is  under  control  of  the  tip  of  the  left  index-finger. 
The  button  is  quickly  pushed  and  the  tube  sent  home  with  the  tip  of  the 
left  finger.  The  introducer  removed,  the  thread  loosely  held,  the  opera- 
tor listens  for  the  peculiar  whistling  cough  (always  to  follow)  which 
announces  the  successful  seating  of  the  tube  in  the  larynx.  Failure  to 
steady  the  epiglottis,  or  to  elevate  the  introducer  handle  at  the  right 
instant,  sends  the  tube  into  the  oesophagus,  whence  it  may  be  recovered 
with  the  thread  whose  sudden  tightening  shows  its  location  in  the  gullet. 
The  trachea  will  never  swallow  the  tube.  The  disposition  of  the  thread 
may  depend  upon  circumstances.  Many  European  operators  leave  it 
attached  securely  to  the  left  ear  or  to  the  left  cheek  by  a  piece  of  adhe- 
sive plaster.  Americans  usually  cut  and  withdraw  it  cautiously  a  few 
minutes  after  the  tube  is  settled,  steadying  the  tubehead  with  the  finger. 
If  the  thread  be  left  it  should  be  passed  back  of  the  bicuspids  to  prevent 
its  being  bitten  in  two.  If  the  tube  be  coughed  up  it  must  be  replaced. 
If  the  loosened  membrane  be  pushed  ahead  of  the  tube  it  will  probably 
be  coughed  out  at  once;  if  not,  and  the  breathing  stop,  it  must  be 
removed.  If  the  membrane  be  still  impacted,  tracheotomy  must  be  done 
quickly.  With  this  in  view  the  arrangements  for  that  operation  should 
be  made  before  the  intubation.  Fortunately,  tracheotomy  is  very  rarely 
necessary.  Gentleness  in  tube  introduction  is  necessary  to  avert  the 
making  of  a  false  passage.  If  the  tube  point  be  kepi  exactly  in  the 
median  line  there  is  but  little  danger  of  its  engagement  and  arrest  in  the 
ventricle  of  the  larynx. 

The  length  of  time  a  tube  should  be  worn  is  from  one  to  five  days. 
The  use  of  antitoxin  has  shortened  the  period.     After  the  first  day  or 

37 


578  THE    SPECIFIC    INFECTIOUS    DISEASES 

two,  with  signs  of  improvement,  the  tube  may  be  withdrawn  tentatively. 
If  marked  dyspnoea  result  it  must  be  returned.  Prolonged  wearing  of 
the  tube  may  lead  to  ulceration  by  pressure  at  its  lower  end,  hence  the 
need  for  early  removal.  Extubation  is  somewhat  more  difficult  than 
introduction.  The  same  preparation  and  routine  must  be  followed ;  the 
finger  serving  as  a  guide  to  the  head  of  the  tube  into  which  the  beak 
of  the  extractor  is  quickly  inserted;  the  mandibles  separated  by  firmly 
depressing  the  lever,  and  the  tube  lifted  straight  upward,  then  outward 
by  reversing  the  movements  of  introduction.  If  a  tube  be  coughed  up 
repeatedly  a  size  larger  should  be  tried. 

In  all  manipulations  one  thing  must  be  kept  in  mind, — not  to  shut 
off  the  child 's  air  for  longer  than  ten  seconds.  There  should  be  delibera- 
tion in  preparation  and  celerity  in  execution.  If  difficulties  are  en- 
countered, repeated  trials  should  take  the  place  of  a  long-continued 
effort  during  which  the  child  may  suffocate. 

Feeding  with  the  tube  in  situ,  to  avoid  the  slight  danger  of  aspiration 
of  liquids,  may  require  semisolid  food — as  custard,  junket,  mush,  etc. — 
or  infants  may  be  fed  through  the  oesophageal  tube  passed  through  the 
nose  or  mouth.  Casselberry 's  method  of  feeding  with  the  head  lowered 
is  practised  by  many  physicians. 

TYPHOID   FEVER — ENTERIC   FEVER. 

Typhoid  fever  is  an  acute  infectious  disease  caused  by  the  bacillus 
typhosus  (Eberth's  bacillus),  which  gains  entrance  through  food  or 
drink. 

The  source  of  the  infection  is  always  the  excreta  (faeces  or  urine)  of 
some  typhoid  fever  patient  and  may  have  been  conveyed  some  distance 
in  water  polluted  with  human  dejecta.  Soiled  clothing  and  rags  used 
about  a  patient  may  furnish  a  vehicle,  and  want  of  cleanliness  in  the 
household  of  a  typhoid  patient  is  a  common  cause  of  its  extension  to 
other  members.  Flies  carry  the  infection,  and  probably  dust  containing 
dried  excreta  may  be  wind-borne  from  long  distances.  Many  isolated 
cases  can  be  explained  in  no  other  way.  The  common  means  of  germ 
dissemination,  however,  is  through  polluted  water,  whether  used  for 
drinking,  dilution  of  milk,  or  for  rinsing  fruit,  vegetables,  milk-cans,  or 
ice.  Statistics  abound  showing  a  remarkable  decrease  in  typhoid  fever 
following  improvement  in  the  water  supply  of  cities  and  communities. 
In  some  instances  this  reduction  in  morbidity  reaches  as  high  as  90 
per  cent. 

Of  the  predisposing  causes  it  must  suffice,  from  lack  of  space,  to  men- 
tion but  three, — season,  age,  and  condition. 

Season. — Statistics  show  that  more  than  half  of  the  year's  typhoid 
fever  is  reported  in  the  three  fall  months,  hence  "autumnal  fever." 

Age. — It  is  customary  for  text-books  and  treatises  to  represent  ty- 
phoid fever  as  infrequent  at  the  extremes  of  life  and  to  quote  statistics 
showing  that  the  period  from  fifteen  to  thirty  years  includes  more  than 
half  of  all  reported  cases.     Although  many  clinicians  and  the  profession 


TYPHOID    FEVER  579 

at  large  have  frequently  diagnosed  typhoid  fever  in  infants,  some 
pathologists  have  refused  to  admit  its  possibility,  claiming  that  the 
disease  is  not  common  in  early  childhood  and  that  it  is  rarely,  if  ever, 
seen  before  the  third  year.  In  support  of  this  attitude  they  cite  reports 
of  autopsies  by  the  thousands,  covering  a  long  period  of  years  made  in 
hospitals  for  children  and  foundling  asylums,  in  which  the  characteristic 
lesion  (intestinal  ulceration)  was  not  found.  Until  recently  no  other 
means  of  positive  identification  of  this  disease  in  its  atypical  forms  was 
recognized.  During  the  past  decade  the  widely  increasing  employment 
of  the  diazo  reaction,  Widal  reaction,  and  of  blood  examination,  has 
placed  the  diagnosis  of  typhoid  fever  beyond  the  need  of  post-mortem 
confirmation,  and  reports  are  rapidly  multiplying  of  unquestionable 
typhoid  in  young  children  and  infants.  Xo  valid  reason  has  ever  been 
advanced  why  infants  should  be  exempt  from  typhoid  fever  other  than 
the  partial  immunity  of  nurslings  to  all  infections  which  come  through 
unsterilized  food  and  drink,  because  of  their  freedom  from  exposure.  By 
the  above-mentioned  means  of  greater  precision,  typhoid  fever  is  now 
diagnosed  in  young  children  in  whom  the  disease  was  formerly  only 
surmised  from  the  absence  of  other  known  cause  for  the  clinical  phe- 
nomena. A  systematic  routine  examination  of  infants  showing  fever 
and  malaise  during  the  prevalence  of  typhoid  fever  will  bring  to  light 
many  unsuspected  cases  of  the  disease.  It  is  too  early  to  attempt  any 
systematic  tabulation  of  this  newer  class  of  typhoid  patients,  as  the 
necessary  observations  are  yet  far  from  general.  Two  facts,  however, 
are  established  from  the  reports  along  this  line  of  work :  first,  typhoid 
fever  in  infants  rarely  furnishes  the  clinical  picture  as  seen  in  adults ; 
second,  the  intestinal  lesions  formerly  regarded  as  pathognomonic  of 
this  disease  (enteric  fever)  are  usually  wanting  or  greatly  modified. 

Condition. — The  increasing  frequency  of  positive  Widal  reaction  in 
infants  suffering  from  marasmus  and  summer  dyspepsia  suggests  an 
increased  susceptibility  to  infection  by  Eberth's  bacillus,  especially  when 
other  members  of  the  household  show  immunity.  Lowered  resistance 
from  previous  disease,  or  from  a  catarrhal  condition  of  the  digestive 
tract,  is  probably  a  predisposing  cause  of  typhoid  fever. 

PECULIARITIES  OP  THE  INFANTILE  FORM   OF  TYPHOID  FEVER. 

Only  some  of  the  principal  peculiarities  of  typhoid  in  infants  as 
compared  with  the  well-known  adult  type  will  be  briefly  mentioned. 

Lesions. — As  before  stated,  extensive  ulceration  of  the  intestine  is 
not  common  in  this  class.  Fetal  typhoid,  of  which  there  are  several 
recorded  instances,  shows  no  bowel  lesion  whatever,  although  Eberth's 
bacillus  may  be  found  in  the  blood,  bile,  and  various  viscera  and  tissues. 

Fatal  postnatal  typhoid  may  show  only  swelling  or  perhaps  super- 
ficial necrosis  of  portions  of  the  agminate  and  solitary  glands  of  the 
intestine ;  or  when  shallow  ulcers  occasionally  are  found  they  may  be 
indistinguishable  from  similar  lesions  of  enterocolitis. 

Onset. — The  onset  of  infantile  typhoid  is  often  abrupt,  frequently 


580  THE    SPECIFIC    INFECTIOUS    DISEASES 

with  vomiting,  high  fever,  rapid  pulse,  and  occasionally  convulsions. 
Initial  epistaxis  is  rare,  although  it  may  occur  later  during  the  pyrexia 
or  convalescence.  Pharyngitis  is  not  uncommon,  and  erythematous  or 
urticarial  rashes  may  accompany  the  onset  or  complicate  the  clinical 
picture  at  any  stage  of  the  disease.  Splenic  enlargement,  although 
earlier  in  evidence,  is  not  so  constant  nor  usually  so  marked  as  in  the 
adult  form,  nor  is  hepatic  enlargement  always  demonstrable.  Persistent 
splenic  enlargement  is  usually  noted  in  relapse.  The  rose  spots  occa- 
sionally appear  during  the  first  week,  and  herpes  labialis  is  not  uncom- 
mon. Contrary  to  what  might  be  expected,  bronchitis  is  not  a  regular 
accompaniment  of  infantile  typhoid.  This  form  of  the  disease  is  less 
severe  and  its  course  is  usually  shorter  by  a  week,  yet  relapses  are 
probably  more  frequent. 

Blood  examination  shows  earlier  positive  "Widal  reaction,  early  and 
rapid  reduction  of  haemoglobin,  earlier  leucopenia,  but  with  a  quicker 
return  towards  the  normal  leucocyte  count.  More  rapid  increase  is  seen 
after  the  second  week  in  the  mononuclear  elements,  especially  in  the 
lymphocytes,  and  always  quicker  leucocytic  response  to  complications 
which  increase  their  number. 

Abdominal  Symptoms. — Tympanitis  is  less  frequent  or  extreme  and 
iliac  gurgling  and  tenderness  are  usually  absent,  while  extremes  of  con- 
stipation and  diarrhoea  are  not  the  rule.  The  stools  are  rarely  the 
characteristic  "pea-soup"  movements  of  the  adult,  but  may  contain 
curds,  mucus,  or  undigested  food,  as  in  ordinary  enterocolitis. 

The  period  of  anorexia  is  not  so  prolonged  and  is  less  pronounced, — 
children  in  the  hospital  ward  frequently  crying  for  food  during  the 
pyrexia.  Intestinal  hemorrhages  and  perforation  are  less  frequent  and 
occur  oftenest  during  a  relapse. 

Nervous  Symptoms. — Headache  is  quite  common,  also  restlessness, 
which  at  night  is  sometimes  almost  a  querulous  delirium.  Apathy, 
stupor,  and  coma  are  not  so  frequent,  but  when  seen  may  form  part  of 
a  symptom  complex  simulating  cerebral  meningitis.  There  may  be 
exaggerated  knee-jerk,  ankle-clonus,  Kernig's  sign,  and  even  transient 
partial  hemiplegia.  True  meningitis,  which  but  rarely  complicates  adult 
typhoid,  is  believed  to  occur  more  commonly  as  a  complication  in  children. 

Heart. — Cardiac  inflammations  are  rarely  met  with,  but  a  systolic 
bruit,  with  some  dilatation  of  the  left  ventricle,  is  common,  as  during 
other  infectious  fevers  in  children,  and  subsides  with  return  to  conva- 
lescence. Otitis,  as  a  complication  and  suppurative  parotitis  in  the 
third  week,  are  rather  peculiar  to  children ;  so  also  is  aphasia,  which  is 
frequently  observed  during  convalescence  and  from  which  children 
usually  recover  in  a  few  weeks.  Fine  desquamation  is  not  uncommon 
after  a  severe  attack.  Furunculosis  occasionally  complicates  conva- 
lescence and  multiple  gangrene  has  been  reported.  Post-typhoid  neuritis 
is  probably  less  frequent  in  children  than  in  adults. 

Diagnosis. — It  is  evident  that  the  clinical  diagnosis  of  typhoid  fever 
may  be  attended  with  great  difficulty  in  infancy  and  childhood,  a  fact 


TYPHOID    FEVER  W 

which  undoubtedly  accounts  for  the  long  prevailing  belief  in  its  rarity 
at  this  period. 

While  the  positive  recognition  of  typhoid  depends  upon  the  agglu- 
tination test  or  the  demonstration  of  Eberth's  bacillus  in  the  excreta, 
blood,  or  rose  spots,  the  difficulties  and  uncertainty  of  cultural  methods, 
and  the  necessary  delay  before  a  positive  Widal  reaction  may  be  ex- 
pected, makes  the  early  diagnosis  depend  upon  the  history,  symptoms, 
and  blood  count.  The  well-known  tendency  in  early  life  to  leucocytosis 
upon  the  slightest  pretext  adds  special  significance  to  leucopenia,  so 
that  febrile  disturbance  attended  by  a  reduction  in  white  corpuscles  is, 
in  itself,  suggestive  of  typhoid  fever.  By  exclusion  of  other  possible 
causes  for  the  leucopenia,  a  tentative  diagnosis  of  typhoid  may  be  made 
in  the  absence  of  typical  symptoms  of  that  disease.  Among  those  causes 
may  be  mentioned  tuberculosis,  measles,  malaria,  and  influenza,  as  well 
as  secondary  anaemias,  or  any  condition  of  profound  disturbance  of  the 
circulation :  like  shock,  prolonged  exposure  to  cold,  quick  hot  baths,  or 
the  action  of  certain  drugs, — as  atropine,  sulphonal,  tannic  acid,  or 
ergot.  The  diagnosis  of  typhoid  is  extremely  difficult  when  the  symp- 
toms resemble  those  of  tuberculous  meningitis,  and  many  apparent  recov- 
eries from  that  disease  were  probably  cases  of  meningeal  typhoid,  a  form 
by  no  means  rare  in  infancy  and  childhood.  Rapid,  regular  pulse  and 
respiration,  normal  pupils  and  retina,  with  negative  lumbar  puncture, 
would  point  rather  to  typhoid  fever,  regardless  of  flat  abdomen,  impal- 
pable spleen,  and  the  signs  and  phenomena  of  Kernig,  Babinski,  and 
Oppenheim.  Further  symptomatic  developments,  including  the  YVidal 
reaction,  may  be  necessary  to  change  doubt  into  certainty. 

Malaria  should  show  the  Plasmodium  and  yield  to  quinine. 

Influenza  shows  no  early  decrease  in  haemoglobin  so  characteristic  of 
typhoid,  otherwise  it  may  baffle  differentiation  for  several  days.  The 
same  may  be  said  of  acute  general  miliary  tuberculosis  when  compared 
with  atypical  typhoid  in  infants  until  diazo  reaction,  rose  spots,  or 
Widal 's  agglutination  determine  the  nature  of  the  disease. 

Prognosis. — Uncomplicated  typhoid,  if  carefully  managed,  is  rarely 
fatal  in  young  patients,  and  fortunately  the  graver  complications  of  the 
adult  type  are  of  rare  occurrence.  In  the  absence  of  definite  data  two 
per  cent,  is  probably  a  high  estimate  of  the  mortality  in  children  before 
the  fifth  year. 

Treatment. — Careful  nursing  and  feeding  will  meet  all  the  require- 
ments of  a  large  majority  of  typhoid  fever  cases,  as  it  is  a  self-limiting 
disease  with  a  quite  definite  course  and  a  tendency  to  recovery.  Pure 
air,  bland  liquid  diet,  and  a  free  use  of  water,  are  of  great  importance 
Hydrotherapy  is  the  sheet-anchor  in  typhoid.  That  it  eliminates  toxins 
and  promotes  leucocytosis  may  be  seen  in  the  reduction  of  pyrexia, 
increase  of  bacilli  in  the  excreta,  increase  in  the  white  blood  corpuscles, 
and  increased  comfort  of  the  patient. 

Baths  may  be  made  to  depend  somewhat  closely  upon  the  range  of 
temperature   and  evidence   of  toxaemia.      The   method   of  bathing,   the 


582  THE    SPECIFIC    INFECTIOUS    DISEASES 

temperature  of  the  water,  etc.,  must  be  governed  by  the  effects,  and  the 
idiosynerasis  of  the  child.  Xo  bath  should  cause  discomfort,  excitement, 
or  fatigue.  Reaction  in  young  children  is  not  good  after  cold  tubbing. 
If  tubbing  be  practised  the  child  should  be  lowered  in  a  blanket  hammock 
to  prevent  shock.  Sponge  bathing  or  the  fan  bath  usually  answers  better 
for  children.  A  gauze  sheet  is  moistened  with  tepid  water  and  alcohol 
(4  : 1),  from  which  evaporation  is  promoted  by  a  current  of  air.  The 
ice-cap  is  invaluable  both  for  high  temperature  and  cerebral  excitement. 
The  hair  should  be  cut  short  in  the  beginning  of  the  disease.  The 
child's  mouth  must  be  kept  clean  by  gentle  applications  of  boric  acid 
solution  on  a  soft  swab  of  gauze.  The  decubitus  should  be  frequently 
changed  by  turning  the  child  in  his  crib. 

The  use  of  drugs  should  be  restricted  to  absolute  indications.  The 
early  use  of  calomel  in  two  or  three  full  purgative  doses  or  in  small  doses 
every  two  or  three  hours  for  a  few  days,  is  of  unquestioned  benefit.  Bro- 
mides may  be  necessary  to  relieve  headache  or  excitement  and  promote 
sleep,  aided  by  bathing. 

Constipation  is  best  relieved  by  moderate  saline  enemata.  Eecords 
of  temperature,  pulse,  and  respiration  should  be  made  every  four  to  six 
hours.  Special  care  is  necessary  to  avoid  traumatizing  the  rectum  in 
the  frequent  use  of  thermometer  and  tube.  Complications  should  be 
anticipated,  as  far  as  possible,  by  constant  watchfulness  on  the  part  of 
the  physician  and  nurse,  and  receive  early  attention.  Intestinal  hemor- 
rhage demands  application  of  an  ice-bag  or  Leiter  coil  to  the  abdomen, 
absolute  quiet,  withdrawal  of  food,  and  the  hypodermic  use  of  morphine. 
In  perforation  the  surgeon  must  be  summoned  without  delay.  In  pro- 
longed cases  or  relapse,  the  heart  failure  should  be  anticipated  by 
strychnine  and  alcohol  in  some  eligible  form,  and  convalescence  should 
not  be  forced  by  early  return  to  solid  food  or  attempts  at  exercise. 
Solid  food  should  not  be  allowed  for  a  week  or  more  after  the  tem- 
perature has  become  normal.  In  suitable  weather  the  child  should  be 
allowed  to  lie  in  the  open  air,  properly  guarded  against  annoyances  or 
excitement. 

Elixir  of  iron,  quinine,  and  strychnine,  as  a  tonic,  may  be  valuable 
after  the  pyrexia.  For  food.  milk,  properly  modified  and  peptonized 
if  necessary,  meets  the  requirements  of  most  cases.  Broths,  raw  meat 
juice,  peptonoids,  egg-water,  koumiss,  and  matzoon  afford  a  choice  for 
sensitive  stomachs. 

Even  the  care  of  the  patient  is  hardly  more  important  than  a  thor- 
ough disinfection  of  the  stools,  urine,  bedding,  and  all  articles  used  in 
the  sick-room.     (Appendix.) 

MALARIA— INTERMITTENT   FEVER  ;   PALUDISM. 

Malaria  is  an  infectious  fever  due  to  the  presence  in  the  blood  of  a 
parasite,  the  Plasmodium  malaria.  The  disease  in  its  typical  form  is 
characterized  by  periodical  paroxysms  of  fever  preceded  by  a  chill  and 
followed  bv  sweating. 


MALARIA  583 

The  ha?matozoon  gains  entrance  through  the  bite  of  a  mosquito 
(genus  anopheles)  which  lias  been  previously  infected,  the  Life  cycle 
of  the  parasite  determining  the  periodicity  of  tin-  exacerbations. 

No  age  is  exempt  from  malaria.  Congenital  casts  have  been  reported 
of  infants  born  of  malarial  mothers.  Infants  are  especially  susceptible 
from  their  great  vulnerability  to  mosquito  bites. 

The  predisposing  cause  is  sojourn  in  wet  marshy  regions,  or  near 
bodies  of  stagnant  water  during  the  warm  season,  where  mosquitoes 
abound.  The  disease,  though  infectious,  is  not  communicable  in  the 
ordinary  meaning.  One  attack  does  not  confer  immunity,  yet  a  degree 
of  toleration  seems  to  follow  long  residence  among  the  mosquitoes. 

The  etiology  and  general  pathology  in  the  infant  do  not  differ  mate- 
rially from  that  of  the  adult,  the  blood  in  addition  to  the  parasitic  phases 
of  the  erythrocytes  showing  pigmented  leucocytes  and  leucopenia  with 
relative  lymphocytosis. 

It  is  in  the  symptomatology  that  infants  show  variations  from  the 
adult  type  of  the  disease,  and  these  only  will  be  considered. 

The  anaemia  is  marked  in  children  and  the  blood  shows  an  early  low 
color  index.  The  differentiation  between  quotidian,  tertian,  and  quartan 
forms  of  the  disease  is  not  usually  well  marked,  nor  is  the  regular 
sequence  of  phenomena  (chill,  fever,  sweating)  common.  Any  of  the 
usual  manifestations  peculiar  to  these  stages  may  be  absent,  or  they 
may  all  be  wanting,  and  in  their  stead,  symptoms  of  visceral  disorder, 
nervous  manifestations,  or  circulatory  disturbances,  may  appear.  Period- 
ical headache,  vomiting,  somnolency,  one  or  all,  may  take  the  place  of 
febrile  paroxysms,  or  the  chill  may  be  replaced  by  delirium  or  in  infants 
by  convulsions.  Recurrent  diarrhoea,  periodical  malaise  with  frontal 
headache,  lassitude,  anaemia,  pallor,  cyanosis,  sleepiness,  cold  extremities, 
cough,  polyuria,  wry-neck,  abdominal  or  epigastric  pains,  and  unex- 
plainable  sweats  or  fever  should,  in  children,  raise  the  question  of 
malaria.  Hepatic  tenderness  is  not  always  demonstrable,  though  splenic 
enlargement  is  rarely  absent,  and  may  be  enormous.  The  spleen  may 
occasionally  be  felt  extending  below  the  umbilicus. 

Malarial  anaemia  is  an  early  sign  in  children,  as  are  other  evidences 
of  cachexia. 

From  an  insidious  onset  the  fever  may  become  almost  continuous, 
with  but  slight  intermissions  which  follow  no  regular  type,  or  it  may 
resemble  typhoid,  meningitis,  or  tuberculosis.  Again,  the  onset  may  lie 
sudden,  with  vomiting,  high  temperature,  and  cough,  with  the  physical 
signs  of  bronchopneumonia.  Pulmonary  symptoms  are  common,  as  the 
infant  lung  shares  readily  the  congestion  of  other  viscera  so  peculiar 
to  malarial  toxaemia.  So  true  is  this  that  frequently  an  attack  is  con- 
strued as  abortive  pneumonia.  Malaria  is  not  incompatible  with  other 
disorders  of  childhood,  any  one  of  which  it  may  simulate  or  complicate. 

Diagnosis. — Formerly  the  diagnosis  of  malaria  in  infancy  and  early 
childhood  was  attended  with  so  many  difficulties  that  the  infection  was 
regarded  as  infrequent  at  this  period.     An  enlarged  spleen   and  the 


584  THE    SPECIFIC    INFECTIOUS    DISEASES 

therapeutic  test  of  quinine  were  the  only  means  of  assurance.  While 
the  former  is  common  to  many  of  the  diseases  of  childhood,  it  is  still  a 
valuable  diagnostic  point  when  considered  with  manifestations  of  an 
intermittent  or  periodic  character.  The  blood,  however,  furnishes  means 
for  a  positive  diagnosis.  Leucopenia  with  pigmentation  of  the  white 
corpuscles  is  alone  sufficient  for  a  probable  diagnosis,  which  the  accom- 
panying periodic  symptoms  may  render  quite  positive.  It  is  for  the 
characteristic  hasmatozoon  of  the  red  corpuscle,  however,  that  search 
should  be  made,  as  its  presence  excludes  all  doubt.  If  the  plasmodia  be 
few  they  may  at  first  escape  detection  by  an  unskilled  observer,  so  that 
the  blood  should  be  taken  just  before  or  at  the  height  of  the  febrile 
paroxysm,  if  such  there  be,  and  with  the  assurance  that  no  quinine  has 
been  administered  during  the  previous  seven  hours. 

Prognosis. — Children  seldom  die  from  malaria,  save  in  its  rare  per- 
nicious form.  The  debility  and  ansemia,  however,  of  persistent  infection 
render  them  especially  liable  to  intercurrent  disorders  which  they  poorly 
resist.  The  prognosis  is  always  good  when  the  disease  is  recognized  and 
proper  treatment  instituted. 

Treatment. — Quinine  is  a  specific  in  malaria,  and  though  other  agents 
are  useful  they  hardly  need  mention,  as  the  efficiency  of  the  former  is. 
beyond  question.  Children  bear  quinine  well  and  it  should  be  given  in 
full  doses,  preferably  just  before  the  paroxysm.  If  the  type  of  the 
disease  be  obscure  the  remedy  may  be  given  three  times  daily,  the  larger 
portion  best  taken  at  bedtime,  to  avoid  the  symptoms  of  cinchonism  to 
which  some  children  are  predisposed.  The  objectionable  bitter  taste 
may  be  obviated,  if  necessary,  by  the  use  of  fresh  capsules,  or  wafers 
when  they  can  be  swallowed.  Syrup  or  elixir  of  yerba  santa  disguises 
the  bitter  taste  if  mixed  immediately  before  taking.  So,  also,  chocolate, 
with  which  the  mouth  may  be  smeared  (chocolate  cream)  just  before  ad- 
ministering the  drug.  Quinine  tannate  in  tablets,  made  up  with  chocolate, 
are  eaten  readily  as  confections  and  answer  where  a  small  dose  is  suffi- 
cient. Quinine  bisulphate  is  most  efficient  because  of  its  ready  solubility. 
The  addition  of  dilute  sulphuric  or  hydrochloric  acid  promotes  the 
solution  and  absorption  of  all  the  alkaloidal  salts.  A  tasteless  prepara- 
tion, recently  introduced,  is  euquinine,  which  is  highly  recommended  by 
those  who  have  used  it. 

In  case  of  gastric  intolerance,  rectal  medication  may  be  employed 
by  clysters  of  the  solution  with  dilute  acid,  or  by  suppositories,  though 
these  are  less  reliable.  An  appreciable  amount  of  the  bisulphate  may 
be  absorbed  by  the  skin  if  rubbed  up  thoroughly  with  oleic  acid,  lard,, 
or  lanolin  (quinine  bisulphate  one  part;  oleic  acid  one  part;  lard  six 
parts).  A  moderate  dose  of  the  quinine  salts  is  one  grain  (0.06  Gm.) 
for  each  year  of  the  child 's  age.  This  should  be  repeated  two  to  four  times 
daily,  or  double  this  dose  administered  just  before  or  at  the  height  of 
the  exacerbation.  In  chronic  cases  arsenic  (Fowler's  solution,  two  to 
eight  drops)  is  a  valuable  adjunct,  and  may  well  be  combined  with  iron 
for  the  anaemia,  as  in  the  elixir  of  iron,  quinine,  and  arsenic,  given  in 


HEREDITARY    SYPHILIS 

teaspoonful  doses  to  a  child  of  five  years.  Chronic  malaria  is  very 
refractory  and  may  continue  in  the  system  indefinitely,  the  spleen  re- 
maining enlarged  in  many  cases.    Such  children  require  a  course  of  the 

above  treatment,  with  moderate  doses  of  calomel  every  few  weeks. 

Prophylaxis  consists  in  the  avoidance  of  mnhirbd  localities  during 
the  mosquito  season,  or,  if  that  be  impossible,  protection  by  netting  at 
doors  and  windows  and  over  the  bed,  and  avoidance  of  t lie*  night  air,  at 
which  time  the  anopheles  is  most  active.  Upper  rooms  are  preferable 
for  sleeping  apartments,  as  these  pests  fly  near  the  ground.  Every 
known  case  of  malaria  should  be  protected  from  the  mosquito  in  order 
to  curtail  the  supply  of  infection. 

HEREDITARY   SYPHILIS. 

'  Syphilis  is  a  communicable  disease  probably  due  to  a  micro-organism 
of  unknown  nature.  No  age  is  exempt.  Infancy  is  subject  to  two  forms 
of  the  disease,  inherited  and  acquired,  the  former  being  much  the  more 
common. 

The  only  practical  difference  between  acquired  syphilis  in  infants 
and  in  adults  is  the  more  acute  symptoms,  rapid  course,  and  greater 
fatality  in  the  former. 

Notwithstanding  the  prevalence  of  syphilis  and  the  amount  of  study 
and  observation  it  has  received,  some  questions  in  regard  to  its  trans- 
mission from  parent  to  child  are  still  sub  judice:  first,  whether  an 
apparently  healthy  mother  can  bear  a  syphilitic  child ;  second,  whether 
a  syphilitic  mother  can  bear  an  apparently  healthy  child ;  third,  whether 
a  syphilitic  father  can  beget  an  apparently  healthy  child ;  fourth, 
whether  an  apparently  healthy  child  can  be  produced  by  parents  both 
of  whom  are  syphilitic ;  fifth,  whether  postconceptional  infection  of  the 
mother  may  include  the  child  in  utero ;  sixth,  whether  an  apparently 
healthy  mother  may  nurse  her  syphilitic  child  with  impunity;  seventh, 
whether  an  apparently  healthy  child  may  nurse  its  syphilitic  mother 
with  impunity. 

The  answers  to  the  first  five  questions  are,  by  the  consensus  of  opinion, 
in  the  affirmative. 

The  sixth  and  seventh  are  yet  considered  doubtful,  notwithstanding 
Profeta's  law  and  Colles's  law  to  the  contrary.  The  question  is  raised 
by  many  as  to  whether  hereditary  syphilis  is  contagious,  as  but  few  cases 
of  undoubted  infection  from  congenital  syphilis  are  known.  The  well- 
known  fact  that  syphilitic  transmissibility  not  only  is  intermittent, 
showing  long  periods  of  quiescence  or  latency,  but  that  it  tends  to 
diminish  with  time,  explains,  no  doubt,  many  apparent  contradictions 
as  to  its  transmission.  The  more  recent  the  infection  in  the  parent  the 
more  certain  is  its  appearance  in  the  offspring,  the  earlier  and  more 
pronounced  are  its  symptoms  and  the  greater  its  fatality.  In  line  with 
the  higher  degree  of  virulence  of  recently  acquired  syphilis  is  the  ten- 
dency to  early  miscarriage;  then  later  miscarriage;  then  premature 
births;    then  viable  but  tainted  babies;    then  apparently  healthy  babies 


586  THE    SPECIFIC    INFECTIOUS    DISEASES 

(a  not  rare  experience  even  in  untreated  cases).  An  apparent  contra- 
diction is  seen  in  the  absence  of  syphilitic  lesions  in  some  of  the  products 
of  these  early  miscarriages. 

The  possibility  of  a  primary  infection  of  the  child  in  the  birth 
passage  of  a  syphilitic  mother  should  not  be  forgotten,  with  subsequent 
development  of  secondary  symptoms,  the  primary  lesion  having  been 
overlooked  or  misinterpreted.  The  diagnosis  of  congenital  syphilis  is 
so  dependent  upon  the  symptom  complex  of  known  lesions  that  it  may 
best  be  approached  by  a  consideration  of  its  pathology.  This  divides 
readily  into  three  parts, — 

(1)  The  mechanical  structures,  including  the  skin  with  its  appen- 
dages, and  the  skeletal  structures. 

(2)  The  mucous  membranes. 

(3)  The  organs  and  viscera. 

The  skin  shows  swelling  and  thickening  of  the  rete  with  intra-  and 
perivascular  infiltration  of  round  cells,  one  result  of  which  is  a  rapid 
shedding  of  epidermal  cells  and  a  transudation  of  bloody  serum  which 
raises  the  epidermal  layer  in  the  form  of  blebs.  These  bullae  appear 
most  frequently  on  the  palms  and  soles,  and  about  the  buttocks,  genitals, 
and  extremities.  They  may  be  sanguino-purulent  and  change  readily 
to  deep  ulcers.  Nonspecific  pemphigus  is  more  serous  in  character  and 
is  rarely  seen  before  the  third  year. 

A  common  skin  lesion  is  roseolous  macula?,  with  well-defined  margins, 
about  the  genitals  and  over  the  face  and  body.  They  are  bright  red  at 
first,  then  change  to  a  brownish  terra  cotta  and  are  followed  by  desqua- 
mation, especially  upon  the  soles  and  palms,  leaving  the  surface  glazed 
and  shiny.  Boils  with  purple  areola?  and  deep  indolent  ulcers,  which 
cause  neither  pain  nor  itching,  are  common. 

The  hair  is  dry  and  scanty,  with  falling  of  eyebrows  and  lashes,  with 
seborrhcea  of  the  brows  and  patches  of  alopecia  of  the  scalp.  Occa- 
sionally the  hair  is  dark,  fine,  abundant,  and  bushy,  which,  in  contrast 
to  the  pallid  skin,  has  been  called  the  "syphilitic  wig."  The  nails  are 
dry,  brittle,  and  stunted.  They  may  be  contracted  laterally,  giving 
them  the  appearance  of  claws.  Pustular  onychia?  develop  in  the  matrix 
or,  later,  dry  verrucous  neoplasms,  from  the  size  of  a  pea  to  that  of  a 
filbert,  overhang  their  lateral  margins. 

The  deciduous  teeth  show  late  eruption  and  early  decay.  The  perma- 
nent set  is  also  delayed  and  shows  irregularities.  The  central  upper 
incisors  especially  are  small,  widely  separated,  converging,  peg-shaped, 
or  notched,  or  concave  on  their  free  edges.  Transverse  striations  or 
erosions  of  the  enamel  occur,  which  may  be  seen  also  on  the  canine  teeth 
or  the  first  molars.  The  latter,  also,  show  loss  of  enamel  on  the  cusps, 
which  are  merely  tubercles  of  yellow  dentin. 

The  skeletal  structures,  bones,  cartilages,  and  articulations  show  char- 
acteristic lesions  in  both  early  and  late  inherited  syphilis.  The  most 
common  of  these  are  osteochondritis  and  epiphysitis  of  the  long  bones  at 
their    distal   ends,   with   separation   of   the   epiphyseal    cartilages    and 


HEREDITARY    SYPHILIS  587 

enlargement  of  the  terminal  tuberosities.  The  cartilages  may  be  soft- 
ened, the  adjacent  articulations  become  invaded  with  pyogenic  microbic 

infection  and  resultant  purulent  arthritis  of  a  low  grade.  Later  the 
periosteum  of  the  shaft  shows  thickening  from  subperiosteal  deposition 
of  bone,  or  from  the  development  of  gummatous  nodules  beneath  it.  The 
skull  bones  may  be  thinned  by  pressure,  especially  the' occipital  (cranio- 
tabes),  or  may  be  thickened,  showing  irregular  enlargements  or  bossae, 
especially  over  the  parietal  and  frontal  eminences,  or  gummatous  nodules 
under  the  periosteum  or  beneath  the  dura  mater.  The  mucous  membrane 
shows  early  catarrhal  lesions,  especially  of  the  nasal  tract,  resulting  in 
the  familiar  coryza  or  "  snuffles,"  with  later  destructive  ulceration  of 
the  nasal  cartilages  and  bones  by  necrosis,  also  by  deep  ulceration  of  the 
pharyngeal  and  faucial  submucous  structures.  Laryngitis  is  common 
and  is  sometimes  followed  by  perichondritis  of  the  laryngeal  cartilages. 

Mucous  patches  form  in  the  mouth  and  later  deep  ulcers  perforate 
the  soft  and  hard  palate.  The  pseudomucous  membranes  rarely  escape. 
Papules,  vesicles,  and  mucous  patches  form  about  the  lips  and  angles  of 
the  mouth,  at  the  corners  of  the  palpebral  fissures,  and  about  the  anus 
and  genitals.  Crusts  may  form  over  these  lesions,  which  crack  and 
bleed,  or  result  in  obstinate  fissures  which  extend  into  the  adjacent  skin, 
leaving,  when  healed,  linear  cicatrices.  In  later  stages,  condylomata 
form  about  the  anus  and  genitals,  and  grow  luxuriantly  in  their  own 
fetid  secretions. 

Of  the  viscera,  the  liver  shows  the  most  constant  changes  in  the  new- 
born and  even  in  the  foetus.  The  hepatitis  may  be  interstitial  or  gum- 
matous, although  the  former  is  more  frequent  in  early  infancy.  Increase 
of  connective  tissue  is  followed  by  atrophy  of  the  liver  cells,  with  inter- 
cellular exudate  and  obliteration  of  the  smaller  portal  and  hepatic 
vessels.  In  the  later  stage  gummatous  tumors  form,  with  zones  of  new 
connective  tissue,  causing  local  or  general  hepatic  cirrhosis,  and  rarely 
ascites. 

The  spleen  rarely,  if  ever,  escapes  enlargement,  and  in  older  children 
shows  gummata  and  interstitial  changes   (syphilitic  splenitis). 

The  pancreas  may  be  enlarged  and  show  diffuse  sclerosis,  or  gumma- 
tous formations  which  accompany  similar  degeneration  of  the  liver, 
spleen,  and  kidneys.  The  latter  organs  may  in  the  later  stages  of  the 
disease  show  chronic  interstitial  nephritis,  with  interstitial  changes  in 
the  adrenals.  The  testicles  may  be  affected  with  chronic  orchitis  and  sub- 
sequent atrophy.  Occasionally  the  thyroid  and  thymus  are  the  seat  of 
interstitial  and  gummatous  changes  similar  to  those  seen  in  the  other 
solid  viscera. 

The  circulatory  system  frequently  shows  changes,  such  as  endar- 
teritis, interstitial  myocarditis,  with  occasional  thrombus  formation  and 
embolism. 

The  nervous  system  is  seldom  affected  in  very  young  infants,  except- 
ing the  hydrocephalus  of  the  new-born,  although  rarely  an  acute  menin- 
gitis may  have  syphilis  for  its  underlying  cause.     Occasionally  chronic 


588  THE    SPECIFIC    INFECTIOUS    DISEASES 

basilar  meningitis  occurs,  though  rarely  in  young  infants ;  pachymenin- 
gitis from  gummata  may  be  encountered  later. 

The  respiratory  tract,  even  in  the  foetus,  is  frequently  the  seat  of 
characteristic  lesions,  the  most  common  of  which  is  interstitial  or  white 
pneumonia.  This  is  a  peribronchial  interstitial  fibrinous  process,  with 
fatty  degeneration  of  the  alveolar  epithelium.  It  may  be  circumscribed 
or  involve  an  entire  lobe.  In  older  children  there  may  be  gummata 
which,  breaking  down,  form  pulmonary  cavities  accompanied  by  bron- 
chiectatic  and  emphysematous  dilatation  and  atelectatic  areas.  The 
larynx  and  rhinopharyngeal  structures  rarely  escape. 

The  ear  is  frequently  involved,  not  only  in  a  low  grade  of  otitis  media 
with  little  or  no  suppuration  or  discharge,  but  bilateral  otitis  interna  and 
atrophy  of  the  auditory  nerves,  followed  by  deafness,  is  not  uncommon. 

In  the  eye  interstitial  keratitis  is  a  frequent  result  of  syphilis  in 
older  children  and  is  occasionally  seen  in  infants;  yet  iritis  is  rare,  as 
are  affections  of  the  chorioid  and  of  the  optic  nerve. 

Symptoms. — The  most  noticeable  symptoms  are  those  due  to  lesions 
of  the  skin  and  mucous  membrane.  The  infant  may  be  born  weazened, 
cachectic,  and  covered  with  bullae  from  which  the  epidermis  slips, 
leaving  large  denuded  areas  of  angry,  parboiled  appearance,  or  the  blebs 
may  be  found  only  on  the  palms  and  soles,  with  roseolous  patches  about 
the  anus  and  genitals.  The  color  of  the  skin  may  be  earthy  or  cyanotic, 
and  the  infant  may  soon  succumb  to  the  low  state  of  vitality  or  to  the 
interstitial  pneumonia.  A  large  percentage  of  these  infants  are  born 
prematurely. 

Frequently,  however,  at  birth  no  symptoms  of  syphilis  are  seen. 
To  all  appearances  the  babe  is  well  nourished.  About  the  third  week, 
in  the  majority  of  cases,  symptoms  of  coryza  ("snuffles")  develop, 
may  persist,  and  may  interfere  with  nursing  from  obstruction  to  the 
respiration.  The  nasal  discharge  increases,  may  become  bloody,  muco- 
purulent, or  fetid,  and  causes  excoriations  upon  the  lip,  so  that  the 
labial  and  facial  lesions  are  at  first  attributed  to  this  cause.  Later, 
crusts  form  about  the  mouth,  or  rhagades  radiate  outwards  from  the 
pseudomucous  membrane  of  the  lips.  Mucous  patches  may  form  in  the 
mouth,  about  the  anus,  or  upon  the  skin  where  it  is  thin  and  moist. 
These  patches  are  slightly  raised,  whitish  areas,  from  one-eighth  to  one- 
half  inch  (3-12  Mm.)  in  breadth,  and  may  be  moist.  Ulcers,  or  bluish, 
indolent  boils  and  pustules,  may  appear.  Blebs  are  seen  on  the  soles  and 
palms,  or  the  skin  in  these  areas  is  dry,  shiny  and  tense.  Onychitis  may 
develop,  and  swellings  may  be  observed  about  the  elbows,  wrists,  knees, 
or  ankles,  which  are  tender.  The  child  cries  when  handled  and  the  cry 
becomes  hoarse  from  the  laryngitis.  Some  rise  in  temperature  will  be 
found,  and  the  child  begins  to  have  a  cachectic  appearance,  loses  weight, 
is  fretful,  and  the  skin  has  a  characteristic  dirty  pale-brown  hue.  The 
eyebrows  show  furfuraceous  scales  or  crusts  and  fall  out,  as  do  the  eye- 
lashes, and  hairs  from  the  scalp. 

Dactylitis  swells  the  proximal  phalanges  of  the  fingers  (one  or  more). 


HEREDITARY    SYPHILIS 

which,  however,  rarely  or  tardily  proceed  to  suppuration  and  bony 
necrosis.  Pseudoparalysis  is  not  uncommon,  and  is  dm-  to  the  pain 
induced  by  motion  from  the  epiphyseal  separation  and  subacute  osteo- 
chondritis, and  most  frequently   involves  the  arm,  one  or  both.     The 

spleen  is  always  enlarged  and  dyspepsia  is  nearly  always  a  marked 
feature.  Rarely  are  all  the  above-described  symptoms  present  in  a 
given  case,  and  the  babe  may  be  under  treatment  for  simple  catarrh 
and  indigestion.  Occasionally  hemorrhages  occur,  not  only  from  the 
nasal  mucosa,  but  subcutaneously,  and  from  the  bullous  eruption,  the 
fissures,  and  orifices,  including  the  umbilicus. 

The  glandular  system  shows  but  little  involvement,  save  occasional 
enlargement  of  the  lymph-nodes  in  the  vicinity  of  extensive  suppurative 
lesions. 

Sypliilis  hereditaria  tarda  is  a  term  applied  to  the  manifestations  of 
that  disease  which  develop  after  the  third  year.  These  may  have  been 
preceded  by  symptoms  of  congenital  sypliilis  in  the  early  months  of  life 
which,  subsiding,  reappear  after  an  interval  of  from  three  to  twenty 
years,  very  frequently  at  or  before  puberty.  Occasionally,  however,  the 
history  of  precedent  symptoms  is  wanting  and  the  first  signs  appear 
during  childhood.  If  these  be  cases  of  true  hereditary  transmission,  the 
virus  must  have  lain  dormant  in  the  child's  system  for  several  years,  or 
have  been  held  in  abeyance  by  some  chemico-vital  force  not  understood. 
The  final  yielding  of  the  tissues  to  the  virus  corresponds  in  point  of  time 
to  the  recognized  periods  of  stress,  in  so  many  instances,  as  to  suggest 
lowered  vital  resistance  as  an  exciting  cause.  This  form  of  late  heredi- 
tary syphilis  is  questioned  by  many  who  claim  that  the  earlier  symptoms 
may  have  been  overlooked  on  account  of  their  mildness  or,  in  the  absence 
of  which,  it  is  argued  that  late  manifestations  represent  an  acquired 
syphilis  whose  initial  and  perhaps  secondary  lesions  have  been  over- 
looked or  misinterpreted.  The  diagnosis  of  a  late  from  an  acquired 
form  of  the  disease  is  therefore  at  times  extremely  difficult  if  not  impos- 
sible. The  lesions  correspond  to  those  of  the  tertiary  stage  of  acquired 
syphilis.  It  is  here  that  the  specific  keratitis  with  its  corneal  opacities  is 
usually  seen,  and  the  occasional  iritis  which  by  its  plastic  adhesion  dis- 
torts the  pupil.  The  characteristic  bone  deformities  from  plastic  perios- 
titis and  gummatous  involvement  are  seen  most  frequently  in  the 
cuboidal  head  with  its  prominent  bossa^  and  the  sword-shaped  tibia  from 
the  deposition  of  new  bone  along  the  shin. 

The  nose  is  exaggerated  retrousse  from  the  caving  in  of  the  bridge 
(saddle  nose),  and  the  palate  may  show  perforation.  Tender  spots  and 
nodules  from  low  grade  of  periostitis  or  gummata  may  be  found  over 
various  long  bones  and  under  the  scalp.  Old  sears  or  indolent  sinuses 
leading  to  necrosed  bone  are  found  in  the  vicinity  of  the  epiphyses  and 
upon  the  forearms,  fingers,  and  legs.  The  lymph  nodes  may  be  enlarged, 
especially  the  cervical,  submaxillary,  epitroehlear.  axillary,  and  inguinal. 
The  oral  mucosa  and  the  skin  about  the  mouth  and  anus  show  the  cica- 
trices of  old  rhagadia,  while  the  teeth  show  characteristic  deformities. 


590  THE    SPECIFIC    INFECTIOUS    DISEASES 

Deafness  is  not  rare,  or  an  indolent,  destructive  otitis  media  may  develop, 
with  occasionally  mastoiditis. 

Probably  the  most  constant  manifestation  of  late  syphilis  is  seen  in 
the  skin  lesions,  which  consist  of  subcutaneous  gummata  which  are  at 
first  hard,  elastic,  grayish  in  color,  with  reddened  borders.  Breaking 
down  they  leave  deep  ulcers,  having  rounded  indurated  borders  and  a 
depressed  base.  They  usually  appear  upon  the  face  and  thighs  and  may 
be  covered  by  crusts.  "When  healed,  these  ulcers  leave  smooth,  white 
scars,  in  contradistinction  to  the  purple  cicatrix  from  the  shallow,  irreg- 
ular, soft  tuberculous  ulcer.  Enlargement  of  the  liver  and  spleen  are 
almost  constant  in  late  syphilis.  There  are  anamiia  and  muddy  pallor. 
The  child  is  undersized,  develops  late  or  not  at  all,  shows  absence  or 
paucity  of  pubic  and  axillary  hair,  small  genitals,  flat  breasts,  and  a 
general  condition  recognized  as  "infantilism."  These  children  furnish 
recruits  to  fill  the  ranks  of  the  epileptic,  imbecile,  degenerate,  and 
demented. 

Diagnosis. — The  diagnosis  of  early  hereditary  syphilis  is  usually  not 
difficult.  The  "snuffles,"  pemphigus,  pseudoparalysis,  osteochondritis, 
mucous  patches  about  anus  and  genitals,  with  enlarged  spleen,  and  the 
cachectic  appearance  of  the  infant,  point  unmistakably  to  inherited 
infection.  The  first  three  symptoms  are  never  found  in  the  early  ac- 
quired disease.  The  difficulty  lies  in  differentiation  between  late  syphilis 
and  the  acquired.  The  history  of  chancre — whether  upon  the  lip  from 
kissing,  eye  or  nose  from  birth  infection,  or  upon  any  mucoid  or  epi- 
dermal erosion  from  contact  with  cloths  or  utensils  used  by  a  syphilitic 
parent  or  nurse — settles  all  doubt. 

The  special  dental  deformities,  such  as  Hutchinson's  teeth,  with  early 
keratitis  and  deafness,  with  the  claw-like  finger  nails,  are  considered 
peculiar  to  the  inherited  form. 

"  Hutchinson's  triad"  has  for  many  years  been  regarded  as  of  diag- 
nostic importance  in  hereditary  syphilis.  Although  each  may  occur 
in  nonsyphilitic  or  even  in  healthy  children,  yet,  taken  together,  they 
should  go  a  long  way  towards  establishing  a  diagnosis.  The  triad  con- 
sists of,  first,  eye  affections, — as  interstitial  keratitis  and  a  peculiar  form 
of  chorioiditis  alveolaris,  atrophic  foci,  and  pigmentary  deposit  in  the 
chorioidea ;  second,  affection  of  the  internal  ear  or  auditory  nerves,  with 
deafness  or  deaf-mutism ;  third,  affection  of  the  teeth,  particularly  the 
upper  middle  incisors,  which  are  small,  peg-shaped,  grayish-white,  with 
notched  edges  and  loss  of  enamel. 

Prognosis. — Hereditary  syphilis  shows  a  high  fatality  never  ap- 
proached in  the  acquired  disease,  as  in  this  form  the  new  being  has  had 
to  cope  with  the  infection  from  the  beginning  of  existence.  Its  far- 
reaching  effects  are  seen  in  the  majority  of  those  who  survive  the  period 
of  infancy.  The  mortality  from  intercurrent  affections  due  to  lowered 
resistance  may  never  be  estimated.  Early  treatment  will  cause  the  dis- 
appearance of  all  symptoms  in  a  fair  proportion  of  cases.  The  abate- 
ment of  syphilitic  symptoms,  however,  does  not  constitute  a  cure,  as 


HEREDITARY    SYPHILIS  591 

they  are  liable  to  return  alter  an  interval  of  years.  Moreover,  the  acci- 
dents of  this  disease,  recognized  as  "parasyphilitic"  symptoms,  such 
as  anaemia,  cachexia,  and  rhachitis,  with  retarded  growth  and  atrophic 
conditions,  furnish  a  constant  menace  to  life  and  health.  The  prognosis 
is  rendered  still  more  unfavorable  if  the  infant,  already  badly  nourished 
and  cachectic,  is  deprived  of  natural  food.  Bottle-fed  babies  furnish  a 
large  proportion  of  the  fatal  cases. 

Treatment. — Prophylaxis  is  all-important.  A  syphilitic  woman  or 
the  wife  of  a  tainted  husband  should  receive  steady  mercurial  treatment 
during  the  entire  period  of  gestation.  At  the  beginning  of  labor  the 
vagina  should  be  thoroughly  disinfected.  This  latter  precaution  should 
always  be  observed  in  any  case  of  suspicious  mucous  lesion  about  the 
genitals  of  the  parturient  woman. 

Children  should  be  jealously  protected  from  infection  from  the 
secretions  of  syphilitic  persons,  whether  parents,  nurse,  friend,  or 
stranger.  Social  rank  or  distinction  is  no  guarantee  of  freedom  from 
infection.  Were  the  foolish  and  criminal  practice  of  kissing  and  pro- 
miscuous fondling  of  babies  abolished,  much  syphilis  in  the  innocent 
might  be  prevented. 

So  important  is  nutrition  that  the  syphilitic  infant  should  not  be 
taken  from  the  breast  which  furnishes  suitable  milk.  If  the  mother 
give  no  history  of  syphilis  she  should  be  cautioned  to  take  particular 
care  to  keep  her  nipples  sound  and  clean;  also  to  cleanse  the  baby's 
mouth  before  nursing;  or  a  wet-nurse  with  syphilitic  history  may  take 
the  child.  In  cases  of  doubtful  etiology  and,  in  fact,  in  all  cases  of 
infected  infants,  great  care  should  be  exercised  to  prevent  the  secretion 
from  moist  lesions  from  coming  in  contact  with  non-infected  persons. 
To  this  end,  as  well  as  for  therapeutic  purposes,  such  lesions  should  be 
dusted  with  calomel  and  bismuth,  equal  parts,  three  or  four  times  daily ; 
and  all  spoons,  cups,  cloths,  etc.,  used  about  the  child  should  be  promptly 
sterilized  by  boiling. 

The  specific  remedy  in  hereditary  syphilis,  as  in  the  acquired  form, 
is  mercury,  of  which  there  are  various  methods  of  exhibition, — as  by 
fumigation,  baths,  inunction,  hypodermic,  and  internal  administration. 
Mercurial  ointment  five  to  fifteen  grains  (0.3-1.0  6m.),  with  an  equal 
quantity  of  lanolin,  may  be  rubbed  into  the  skin  of  a  young  infant,  each, 
day,  varying  the  site  of  application  to  avoid  undue  irritation.  If  objec- 
tionable for  any  reason,  the  protiodide  of  mercury  may  be  given  in 
dissolved  tablets  containing  one-twelfth  to  one-fourth  grain  (0.005-0.016 
Gm.)  three  or  four  times  daily.  In  obstinate  cases  calomel  in  the  same 
dosage  may  prove  more  efficient,  but  may  not  be  sustained  as  long  on 
account  of  its  purgative  properties.  To  correct  diarrhoea,  tannic  acid 
preparations  may  be  used  with  the  mercury.  The  anaemia  calls  for  iron, 
so  that  the  "mixed  treatment"  should  be  employed  either  conjointly  or 
alternately,  for  which  the  syrup  of  the  iodide  of  iron  in  doses  of  from 
three  to  fifteen  minims  (0.2-1.0  C.c.)  may  be  given  three  times  a  day, 
according  to  age. 


592  THE    SPECIFIC    INFECTIOUS    DISEASES 

The  following  is  much  used  and  may  be  given  four  times  in  twenty- 
four  hours  in  one  powder:  calomel,  one-sixth  grain  (0.01  Gm.)  ;  saccha- 
rated  carbonate  of  iron,  three  grains  (0.18  Gm.).  Calomel  is  useful  for 
moist  lesions,  especially  for  condylomata  about  the  anus  and  genitals.  A 
good  method  in  extensive  growths  is  the  following :  Wash  the  parts  thor- 
oughly with  salt  solution,  and  after  drying  slightly,  dust  calomel  freely 
over  the  surface.  The  reaction  is  obvious  and  very  effective.  Foul  and 
obstinate  ulcers  after  cleansing  should  be  touched  with  the  solid  nitrate 
of  silver  every  second  day. 

Severe  rhinitis  is  best  treated  by  irrigation  with  a  nasal  syringe 
daily  with  corrosive  sublimate  solution  (1:4000),  followed  by  the 
application  of  iodoform  ointment  with  a  camel's  hair  pencil. 

The  presence  of  bone  lesions,  gummatous  tumors,  hepatic  and  other 
visceral  lesions,  common  to  the  tertiary  stage,  calls  for  potassium  iodide, 
fifteen  grains  to  one  drachm  (1.0-4.0  Gm. )  daily  in  broken  doses  well 
diluted.  This  also  should  be  alternated  or  accompanied  by  tonics  and 
preparations  of  iron. 

Specific  treatment  must  be  continued  for  a  year  at  least,  or  until  all 
symptoms  have  disappeared,  after  which  it  should  be  resumed  in  courses 
of  a  few  weeks,  once  or  twice  daily.  Good  nutrition  and  supporting  and 
tonic  treatment,  should  not  be  neglected. 

TUBERCULOSIS. 

No  other  disease  has  received  the  amount  of  study  given  to  tuber- 
culosis. While  formerly  it  was  thought  to  be  somewhat  rare  in  infancy, 
it  is  now  known  that  deaths  in  children's  hospitals  and  foundling  insti- 
tutions are  caused  by  this  disease  in  thirty-three  per  cent,  of  all  cases, 
and  that  of  the  remaining  fatal  cases  over  twelve  per  cent,  show  tubercles 
in  latent  form. 

The  tubercle  bacillus  gains  entrance  to  the  tissues  by  many  routes. 
It  may  penetrate  the  mucous  membrane  or  pass  through  the  placenta 
of  the  tuberculous  mother  to  her  child  in  utero.  It  is  found  in  the 
secretions,  excretions,  and  morbid  discharges  when  they  are  derived 
from  parts  involved  in  active  tuberculous  processes,  as  urine  from  a 
tuberculous  bladder  or  kidney,  fa?ces  from  ulcerated  bowels,  or  dis- 
charges from  tuberculous  skin  lesions.  The  organism  is  occasionally 
found  in  the  blood  of  tuberculous  patients,  and  in  the  milk  of  a  tuber- 
culous mother,  but  most  frequently  in  the  secretions  of  the  respiratory 
tract.  The  most  common  method  of  dissemination  is  through  the  sputum, 
which,  dried  and  pulverized,  is  taken  with  food,  drink,  and  inspired  air. 
The  infective  germs  are  omnipresent,  and  that  all  do  not  succumb  to 
the  infection  bespeaks  individual  resistance.  This  resistance  may  be 
overcome  by  lowered  nutrition  of  the  whole  or  a  part,  or  by  a  special 
virulence  of  the  bacillus.  That  the  first  is  most  frequently  the  case  is 
evident  from  the  long  list  of  diseases  now  recognized  as  predisposing 
causes  to  tubercular  infection. 

The  most  prolific  predisposing  cause  is  seen  in  the  lymphatism  of 


TUBEBCULOSIS 


:>'.).>> 


infancy  and  childhood,  and  accords  with  the  period  of  widest  prevalence 
of  the  disease, — during  the  first  three  years  of  Life.  Although  direct 
hereditary  transmission  is  rare,  children  undoubtedly  inherit  a  diathesis 
which  strongly  predisposes  them  to  this  form  of  infection.  In  this  way 
hereditary  syphilis  is  a  predisposing  factor. 

Many  instances  of  tuberculosis  in  early  infancy,  formerly  regarded 
as  evidences  of  heredity,  are  now  known  to  be  due  to  postnatal  infection, 
even  though  developing  and  terminating  fatally  before  the  sixth  week 
of  life. 

Regarding  the  most  common  mode  of  infection  in  early  life,  especially 
as  to  the  relative  frecpiency  of  microbic  entrance  through  the  respiratory 
or  digestive  tract,  widely  varying  opinions  prevail.  Recently  renewed 
interest  in  the  controversy  has  developed,  the  extremes  of  opinion  being 
represented  by  Koch  and  Behring. 

Aside  from  the  question  of  the  identity  of  human  and  bovine  tuber- 


Fig.  211.— Rupture  of  tuberculous  peribronchial  gland  into  trachea.     (Rush  Medical  Museum.) 

culosis,  it  is  well  known  that  milk  affords  an  excellent  culture  medium 
for  many  bacteria,  including  the  bacillus  of  Koch.  It  is  believed  that, 
when  introduced  by  the  ingestion  of  such  milk,  the  cervical  lymph-nodes 
and  probably  the  intestinal  and  mesenteric,  yield  readily  to  their  invasion. 

As  to  the  pathology  it  must  suffice  to  state  that  the  form  most  common 
to  early  infancy  is  the  lymphatic ;  that  tuberculous  meningitis  is  peculiar 
to  later  infancy;  that  childhood  is  especially  marked  by  tuberculosis 
of  the  bones  and  articulations,  and  that  prolonged  latency  is  less  common 
in  infants  than  was  formerly  supposed,  because  of  the  susceptibility  of 
young  tissue  to  tubercular  processes.  This  same  reason  may  explain  the 
rarity  of  the  chronic  pulmonary  form. 

The  lymph  channels  furnish  ready  conveyance  of  the  bacilli  after 

38 


594 


THE    SPECIFIC    INFECTIOUS    DISEASES 


their  passage  through  mucous  membrane  or  skin.  Like  other  foreign 
bodies  in  the  lymph  current,  they  usually  lodge  in  some  neighboring 
gland  with  resultant  adenitis.  Glands  in  which  the  bacilli  are  arrested, 
may  show  hyperplasia  and  undergo  degenerative  changes,  as  hyaline  or 
calcareous,  with  ultimate  extinction  of  the  germ.  The  glands  may  become 
surcharged  with  tubercular  bacilli  and  other  pathogenic  organisms,  leuco- 
cytes, and  connective  tissue  overgrowth.  This  reduces  their  blood  supply 
and  favors  caseous  degeneration,  necrosis  of  the  conservative  envel- 
oping zone,  and  escape  of  the  liquefied  mass  into  adjacent  tissues. 
Through  the  lymph  channels  and  blood  the  bacilli  are  distributed  to 
remote  parts,  the  location  of  the  new  tubercular  process  depending  upon 
the  lowered  resistance,  as  from  injuries. 


Fig.  212.— Rupture  of  peribronchial  lymph-gland  into  oesophagus.    (Rush  Medical  Museum.) 

If  the  general  systemic  resistance  be  low,  or  if  the  bacilli  enter  the 
blood  stream  in  great  numbers,  a  generalized  tuberculosis  of  acute  type 
is  lighted.  The  lymph-nodes  most  susceptible  to  tubercular  invasion  in 
children,  are  those  which  have  been  subject  to  frequent  attacks  of  inflam- 
mation from  catarrhal  processes  of  their  areas  of  drainage.  For  obvious 
reasons  these  are  the  bronchial  glands,  especially  those  situated  at  the 
pulmonary  hilum.  By  enlargement  and  coalescence  these  glands  may 
form  mediastinal  tumors  of  sufficient  size  to  cause  pressure  symptoms. 
By  caseous  softening  of  these  glands  and  rupture  into  adjacent  struc- 
tures, as  the  oesophagus,  bronchi,  or  trachea  (Figs.  211,  212),  the  lung 
becomes  quickly  infected,  resulting  in  acute  pulmonary  phthisis. 

Pulmonary  tuberculosis  runs  a  much  more  rapid  course  in  infancy 


TUBERCULOSIS  595 

than  iu  adult  Life.  In  the  majority  of  cases  it  is  the  upper  Lobes  which 
are  first  invaded,  but  the  tendency  is  to  rapid  generalization  not  only  in 
all  the  lobes  but  throughout  the  system.  In  deaths  from  tuberculosis 
of  any  form  more  than  seventy  per  cent,  show  Lung  changes.  Pulmonary 
tuberculosis,  although  presenting  in  infants  and  children  under  Beven 
years  a  great  variety  of  atypical  manifestations,  after  that  age  conforms 
more  nearly  to  the  adult  forms.  Roughly  speaking,  the  disease  may  be 
divided  into  three  general  types, — 

First,  miliary  form,  in  which  miliary  tubercles  are  scattered  through- 
out the  lung,  upon  the  alveolar  septa,  the  walls  of  the  tubes,  the  intersti- 
tial tissues,  and  under  the  pleura.  Other  organs  may  show  these  miliary 
tubercles.  This  form  may  develop  quite  suddenly  during  convalescence 
from  some  acute  infectious  fever,  or  after  recurrent  attacks  of  bronchitis. 

Among  the  symptoms  of  this  form  there  is  fever  which  may  develop 
insidiously  or  suddenly,  and  may  be  high  as  in  pneumonia  or  low  as  in 
subacute  bronchitis.  The  temperature  is  erratic  and  marked  by  exacer- 
bations and  remissions,  but  rarely  remains  normal  for  an  entire  day. 
Cough  is  present  and  may  be  spasmodic,  like  pertussis,  or  croupy.  Pros- 
tration and  malaise  may  be  marked.  The  physical  signs  are  not  dis- 
tinctive, and  more  nearly  resemble  those  of  subacute  bronchopneumonia. 
As  the  infant  does  not  expectorate,  secretions  for  examination  must  be 
obtained  by  passing  a  tube  into  the  oesophagus,  as  the  swallowed  sputum 
clings  to  its  walls.  The  microscope  may  confirm  suspicion  as  to  the  true 
nature  of  the  disease. 

Not  infrequently  during  an  attack  of  miliary  tuberculosis,  the  devel- 
opment of  meningitis  is  the  first  intimation  of  its  tuberculous  character. 
This  form  of  tuberculosis  is  fatal,  younger  infants  dying  of  the 
pulmonary  disorder  and  older  ones  of  the  meningitis,  if  they  survive 
so  long. 

The  second  type  seen  in  infants  may  be  called  the  marasmic  type. 
It  may  begin  as  a  digestive  disturbance,  for  which  it  is  usually  treated. 
There  may  be  exacerbations  and  intervals  of  improvement,  In  these 
eases  there  are  often  local  tubercular  lesions  of  the  bones,  as  a  dac- 
tylitis (Fig.  207),  enlarged  cervical  glands,  or  the  spleen  may  be  en- 
larged, but  through  it  all  there  is  wasting.  There  may  be  a  history 
of  tuberculosis  in  the  family  to  guide  the  diagnosis,  and  the  infant  may 
have  been  weakly  from  birth.  The  slight  cough  may  at  first  attract  bnt 
little  attention.  In  older  infants  and  young  children  some  positive  bone 
or  joint  lesion  may  precede  the  more  acute  attack,  such  as  cervical  or 
dorsal  spondylitis,  or  hip-joint  disease. 

There  is  great  prostration  and  emaciation,  with  capricious  appetite 
and  frequently  marked  anorexia. 

The  pulmonary  symptoms  develop  sometimes  quite  suddenly,  with 
high  temperature,  rapid  respiration,  pain  in  the  chest  suLrirestive  of 
pleurisy,  and  restricted  cough.  The  physical  signs  point  to  acute 
fibrinous  pneumonia,  and  the  child  quickly  succumbs.  It  may  rarely 
follow  a  protracted  course  with  pleurisy  and  empyema.     The  special 


596  THE    SPECIFIC    INFECTIOUS    DISEASES 

feature  of  this  type  is  more  or  less  steady  wasting,  which  most  fre- 
quently ends  abruptly  in  acute  pneumonia. 

The  third  type  is  seen  most  frequently  in  children  past  the  age  of 
five  years.  They  are  delicate,  thin-skinned,  and  have  prominent  wing- 
like scapulae  between  which  the  skin  shows  a  growth  of  fine  hair.  The 
chest  may  be  long  and  flat,  while  the  triangle  of  which  the  clavicle  forms 
the  hypothenuse  is  large  and  sunken.  The  chest  and  head  may  give 
evidence  of  early  rhachitis,  or  the  child  may  have  a  syphilitic  history. 

No  serious  disease  may  have  affected  the  child,  but  a  succession  of 
transient  spring  and  winter  catarrhs  is  reported,  or  the  exanthemata 
may  have  left  slight  but  persistent  attacks  of  bronchitis.  The  tonsils 
are  usually  enlarged  and  adenoid  vegetations  of  the  nasopharynx  are 
common.  Enlargements  of  the  cervical  lymph  nodes,  which  have  oc- 
curred at  various  times,  show  a  tendency  to  become  permanent  and 
may  be  very  pronounced.  Previous  ulceration  of  a  gland  may  have 
left  an  angry  cicatrix  upon  healing.  Otitis  media,  with  discharge  of 
pus  from  one  or  both  ears,  may  have  impaired  the  hearing. 

The  child,  which  has  been  regarded  as  delicate  for  years,  may  be 
dull,  backward,  listless  and  a  mouth-breather,  or  extremely  bright  and 
precocious  and  of  a  highly  nervous  temperament.  The  growth  in  height 
may  be  rapid,  but  the  child  does  not  put  on  flesh,  and  the  weight  re- 
mains the  same  for  long  periods.  Evidence  of  intrathoracic  pressure 
from  mediastinal  tumors  may  develop.  There  may  be  tachycardia, 
asthma,  or  dyspnoea  after  exertion,  with  fulness  and  throbbing  in  the 
vessels  of  the  neck  when  the  head  is  retracted.  The  pulse  is  always 
rapid,  and  while  apparently  in  ordinary  health,  the  thermometer  may 
show  febrile  exacerbations,  especially  at  night.  The  sleep  is  not  rest- 
ful, and  there  is  occasional  sweating  in  the  latter  part  of  the  night. 
The  child  is  languid  and  shows  dark  circles  under  the  eyes.  Respira- 
tion will  be  found  rapid,  especially  upon  slight  exertion,  and  every 
draught  induces  coughing,  which  is  attributed  to  tickling  in  the  throat. 
The  pharyngeal  wall  looks  glazed  and  dark  red,  with  the  follicles  en- 
larged. 

Several  years  may  elapse  before  some  acute  "cold,"  more  per- 
sistent than  its  predecessors,  may  be  pronounced  by  the  physician 
bronchopneumonia ;  an  attack  of  measles  or  whooping-cough  occurs,  with 
delayed  convalescence,  after  which  there  is  a  constant  cough  with  some 
daily  temperature.  Careful  examination  of  the  chest  may  now  reveal 
signs  of  an  unresolved  pneumonia  or  of  a  chronic  interstitial  pneu- 
monia. In  some  instances  careful  and  repeated  examinations  may  locate 
vomica?,  although  in  children  this  is  at  times  extremely  difficult,  as 
cavities,  while  not  infrequent,  are  usually  filled  with  secretions  and 
debris.  The  common  occurrence  of  bronchiectasis  with  atelectatic  and 
emphysematous  areas  renders  the  physical  signs  ambiguous.  Occasion- 
ally, however,  a  child  of  eight  years  will  furnish  a  typical  picture  of 
adult  phthisis  pulmonalis.  The  finger  tips  show  signs  of  clubbing.  Res- 
piration, pulse,  temperature,  emaciation,  languor,  anorexia,  sweats,  cough, 


TUBERCULOSIS 


597 


and  hectic  flush,  may  combine  to  form  a  picture  of  tuberculosis  pul- 
monalis  of  the  chronic  type  (Fig.  213). 

The  blood  findings  are  inconclusive  in  tubercular  disease.  In  acute 
cases  the  erythrocytes  and  haemoglobin  are  but  little  affected,  and  a 
leucocytosis  means  some  accidental  pyogenic  infection.  In  prolonged 
cases  anaemia  finally  asserts  itself  in  the  diminution  of  haemoglobin  and 
some  loss  of  the  red  cells.  In  later  stages  the  anaemia  may  be  marked. 
Haemoptysis  is  unusual  in  children  and  extremely  rare  in  infancy. 

Prognosis. — The  prognosis  is  more  favorable  in  this  third  type  than 
in  the  first  and  second.    The  process  may  cover  a  period  of  years  during 

which  the  nature  of  the  disease  is 
hardly  more  than  suspected.  Much 
depends  upon  early  recognition, 
prompt,  judicious  treatment,  and  the 
degree  of  resistance  in  the  individual 
case.  The  personal  equation  depends 
quite  largely  upon  the  family  history. 
If  this  be  good  the  prognosis  is  hope- 
ful up  to  the  stage  of  cachexia. 

Diagnosis. — The  diagnosis  is  made 
from  the  consensus  of  symptoms  and 
history  and  by  exclusion  of  other 
definite  causes  for  the  wasting.  It  is 
claimed  that  the  blood  of  the  tuber- 
culous shows  agglutinating  properties 
with  properly  prepared  cultures  of 
the  bacilli.  The  tuberculin  test,  while 
still  employed  by  some  reputable  phy- 
sicians, should  be  regarded  as  of 
doubtful  propriety.  A  blow  of  the 
hammer  may  demonstrate  the  true 
nature  of  dynamite.  Sputum  exami- 
nations should  never  '  be  neglected. 
In  young  children  and  infants  the 
tube  may  be  passed  into  the  oesopha- 
gus, or  the  pharynx  may  be  wiped 
with  a  swab. 

Brain  tuberculosis  probably  occurs  through  the  blood  current  which 
carries  the  bacilli  to  the  capillaries  of  either  the  white  or  gray  matter. 
Characteristic  solitary  or  multiple  tubercles  develop,  and  the  latter, 
coalescing,  may  form  tumors  varying  in  size  from  a  pea  to  a  walnut, 
which  give  rise  to  pressure  symptoms,  or  if  superficial  may  cause  menin- 
gitis.    (See  Diseases  op  the  Nervous  System.) 

Subcutaneous  abscesses  are  frequently  the  result  of  subjacent  bone 
necrosis,  with  sequestrum  formation  and  fistulous  openings,  which  dis- 
charge sanious  pus  and  bone  debris.  The  principal  articulation  in- 
volved in  tubercular  processes  is  that  of  the  femoral  head,  while  both 


Fig.  213.— Boy,  aged  3  years.  Pulmonary  and 
mesenteric  tuberculosis,  with  large  liver.  (Dr. 
J.  C.  West.) 


598  THE    SPECIFIC    INFECTIOUS    DISEASES 

bony  necrosis  and  absorption  of  interarticular  cartilages  is  best  illus- 
trated by  spondylitis. 

GLANDULAR    TUBERCULOSIS. 

Formerly  regarded  as  one  of  the  manifestations  of  scrofula  (a  term 
now  obsolete),  tuberculous  adenitis  was  considered  a  menace  to  life  from 
its  frequent  clinical  relation  to  tabes  mesenterica,  osteomyelitis,  and 
pulmonary  phthisis,  all  of  which  are  now  known  to  be  merely  different 
phases  of  tubercular  infection  in  which  adenitis  is  often  the  primary 
lesion. 

Tuberculous  adenitis  exceeds  in  frequency  all  other  glandular  affec- 
tions combined.  Probably  in  half  of  all  autopsies  upon  children  some 
tuberculous  lymph-nodes  may  be  found,  most  frequently  in  the  bron- 
chial, mesenteric,  or  retroperitoneal  areas  which,  on  account  of  their 
location,  are  rarely  'observed  ante-mortem.  Of  the  accessible  glands, 
the  cervical  outnumber  in  frequency  of  involvement  all  the  others,  after 
which  in  order  come  the  axillary  and  the  inguinal.  While  no  age  is 
exempt,  this  affection  is  common  to  the  first  decade  of  life. 

That  other  bacteria  are  associated  with  the  tubercle  bacillus  is  well 
established,  and  undoubtedly  they  act  both  as  predisposing  and  deter- 
mining causes  in  the  adenitis.  In  this  way  such  lesions  as  eczema  of 
the  scalp  and  face,  sore  lips,  carious  teeth,  various  forms  of  stomatitis, 
affections  of  the  tonsils,  nasopharyngeal  catarrh,  adenoids,  and  otitis, 
are  largely  responsible  for  the  non-resistance  of  the  cervical  lymph-nodes 
to  invasion  of  the  bacilli  and  for  their  pathogenic  activity  in  the  arresting 
glands.  It  is  now  known  that  the  tonsil  not  only  furnishes  a  ready  portal 
of  entry  but  is  the  occasional  seat  of  tuberculous  processes,  a  fact  of  the 
greatest  etiologic  importance. 

Symptoms. — Glands  which  may  be  palpated  are  the  seat  of  adenitis. 
Examination  of  children  who  crowd  the  dispensaries  and  out-patient 
clinics  show  less  than  five  per  cent,  free  from  palpable  glands.  The 
symptoms  are  often  those  of  malnutrition,  maldevelopment,  and  evidences 
of  unhygienic  life  and  surroundings. 

If  the  adenitis  be  purely  tuberculous  there  may  be  no  other  specific 
symptoms  until  softening  from  caseous  degeneration  in  a  later  stage. 
Whether  this  caseation  and  softening  would  ever  occur  without  super- 
added infection  or  lowered  nutrition  it  is  impossible  to  say,  but  it  is 
probable  that  some  benign  form  of  degeneration  of  the  gland  would 
terminate  the  pathogenic  career  of  the  bacilli.  In  a  moderate  degree 
<of  infection  with  Koch's  bacilli,  therefore,  the  adenitis  tends  to  run 
a  chronic  course,  with  few  or  no  symptoms,  towards  ultimate  recovery. 

Glands  quiescent  after  old  and  repeated  involvements,  may  flare  up 
suddenly  in  acute  exacerbation  with  constitutional  symptoms  of  intoxica- 
tion and  rapid  extension  of  adenitis  to  adjacent  glands,  which,  coalescing, 
lorm  matted  tumors  on  the  sides  of  the  neck. 

With  pyrexia,  coated  tongue,  malaise,  anorexia,  and  headache,  the 
enlarged  glands  may  soften,  perforate  the  skin,  and  discharge  pus. 
The  abscess,  if  tuberculous,  is  chronic,   continuing  to  discharge  until 


ABDOMINAL  TUBERCULOSIS  599 

all  the  gland  has  broken  down,  and  usually  until  neighboring  deeper 
glands  have  gone  through  a  similar  process,  healing  finally  with  red, 
unsightly  cicatrices. 

Diagnosis. — The  presence  of  chronic  adenitis  of  the  neck,  which 
may  be  attributed  to  no  local  lesion,  is  presumptive  evidence  of  tuber- 
culosis. This  is  especially  true  if  there  be  a  history  of  family  tuber- 
culosis or  exposure  to  infection.  Simple  adenitis  tends  to  undergo  reso- 
lution, with  subsidence  of  the  gland.  Pyogenic  adenitis  tends  to  early 
suppuration,  with  prompt  healing.  Syphilitic  adenitis  is  more  general 
and  symmetrical  in  its  distribution,  gives  a  history  or  shows  other  signs 
of  that  disease,  and  yields  to  mercury. 

Hodgkin's  disease  is  rarely  found  in  early  childhood,  and  usually 
shows  more  extensive  glandular  and  splenic  involvement  and  earlier 
anajmia  with  a  lower  temperature  than  is  seen  in  tuberculosis  of  that 
extent.  There  are  eminent  observers,  however,  who  consider  the  two 
diseases  identical. 

Lymphosarcoma  may  at  first  simulate  tuberculosis  of  the  glands,  but 
its  malignant  nature  is  not  long  concealed. 

ABDOMINAL    TUBERCULOSIS. 

Post-mortems  upon  children  dying  of  tuberculosis  show  lesions  of 
the  abdominal  organs  in  more  than  seventy  per  cent,  of  cases.  In  a 
large  majority  of  these  there  is  ulceration  of  the  bowels  and  caseous 
degeneration  of  the  mesenteric  glands.  In  a  few  there  is  mesenteric 
tuberculosis  without  intestinal  lesions,  but  ulceration  rarely  exists  with- 
out mesenteric  involvement.  Nor  is  this  strange,  since  the  intestinal 
mucosa  with  its  lymphoid  structures  bears  a  relation  to  the  mesenteric 
and  abdominal  glands  similar  to  that  which  exists  between  the  upper 
respiratory  mucosa  and  the  cervical  and  bronchial  lymph  nodes. 

Recent  research  seems  to  lead  to  the  conclusion  that  the  portal  for 
primary  infection  is  more  frequently  through  the  intestinal  tract  than 
previous  opinions  have  been  willing  to  allow,  and  that  the  thoracic  duct 
furnishes  a  ready  avenue  for  the  distribution  of  bacilli  with  resultant 
general  miliary  forms  of  the  disease.  The  modern  conservative  attitude 
is  a  natural  reaction  from  the  older  practice  of  regarding  every  case 
of  fatal  wasting,  with  diarrhoea,  as  "consumption  of  the  bowels,"  pure 
and  primary,  in  which  no  other  tuberculous  lesion  need  be  expected.  It 
is  the  fact,  however,  regardless  of  the  controversy  concerning  the  rela- 
tive frequency  of  the  location  of  the  primary  lesion,  that  infants  do 
occasionally  come  to  post-mortem  with  tuberculous  lesions  of  the  bowels 
and  mesenteric  glands  to  the  exclusion  of  all  other  organs  and  structures. 

While  common  to  all  ages,  infants  in  the  first  year  are  less  frequently 
found  suffering  from  intestinal  tuberculosis,  and  those  at  the  breast 
rarely,  unless  nursed  by  a  tuberculous  mother.  At  the  post-mortem  the 
lung  lesions  which  hasten  the  fatal  termination  are  usually  found.  The 
ileum  and  caecum  are  the  most  frequent  sites  for  ulcers  which,  if  recent, 
present  a  "punched-out"  appearance.     Old  ulcerations  run  crosswise 


600  THE    SPECIFIC    INFECTIOUS    DISEASES 

of  the  bowel  and  show  thickened,  irregular  margins ;  and  the  intestinal 
walls,  especially  of  the  cascum,  may  be  considerably  thickened.  The 
appendix  is  occasionally  the  seat  of  tuberculous  ulceration,  and  healed 
lesions  may,  by  contracting  cicatrices,  produce  stenosis  of  the  bowel  with 
obstruction. 

The  mesenteric  glands  show  different  stages  of  caseous  degeneration; 
the  mesentery  and  adjacent  structures  may  be  agglutinated  by  plastic 
exudation;  tubercles  are  found  in  the  capsule  of  the  liver,  and  peri- 
hepatitis may  lead  to  hepatic  cirrhosis  with  ascites  (Fig.  213). 

Symptoms. — There  is  diarrhoea,  fever,  abdominal  pain,  and  wasting. 
The  abdomen  may  be  distended  with  flatus  or 
fluid  and  show  stasis  of  its  superficial  veins, 
or  it  may  be  flat  and  retracted.  In  long- 
continued  cases  the  enlarged  and  matted 
glands  may  occasionally  be  felt  through  the 
abdominal  wall  by  skilful  palpation  when  the 
distention  is  not  extreme. 

There  is  the  usual  evening  rise  in  temper- 
ature of  tuberculosis,  with  general  wasting 
and  malaise.  The  symptoms  are  those  of 
chronic  enterocolitis  with  marasmus,  while 
the  dejecta  are  not  characteristic  (Fig.  214). 
Diagnosis. — Intestinal  and  mesenteric  tu- 

Fig.  214.— Mesenteric  and  pulmon-       ,  ,      .        ,        ,  ,  ,    ,  , 

ary  tuberculosis.  berculosis  should  not  be  pronounced  upon  in 

the  absence  of  corroborative  tuberculous  mani- 
festations. Careful  examination  of  the  lungs,  and  lymph-nodes  in  other 
parts  should  be  frequently  made  and  a  review  of  the  child's  history  and 
environment  should  enter  into  the  estimate.  The  chronic  obstinacy  of 
the  enteritis,  the  night  fever,  the  history  of  infection,  and  above  all  the 
demonstration  of  tuberculous  lesions  elsewhere,  especially  in  the  lungs, 
may  be  necessary  to  a  diagnosis.  Quite  frequently  the  diagnosis  is 
reversed  by  the  autopsy,  the  case  proving  to  have  been  chronic  ileo- 
colitis with  terminal  acute  bronchopneumonia  of  nontubercular  type. 

PERITONEAL    TUBERCULOSIS. 

It  is  doubtful  if  chronic  general  peritonitis  occurs  in  childhood  in 
the  absence  of  tubercle.  The  disease  is  not  rare.  It  may  be  primary, 
yet  most  frequently  it  is  a  local  expression  of  the  general  infection.  A 
number  of  varieties  are  usually  described  dependent  upon  the  location 
of  the  lesions  and  the  behavior  of  the  tissues  in  the  process  of  tuber- 
culization. For  ordinary  clinical  purposes  two  forms  will  suffice,  the 
wet  and  the  dry,  or  the  ascitic  and  the  plastic. 

The  first  is  characterized  by  large  fluid  accumulations  in  the  abdo- 
men, with  little  or  only  occasional  pain,  some  tenderness  on  pressure, 
alternating  diarrhoea  and  constipation,  little  if  any  fever,  moderate 
malaise,  and  loss  of  flesh.  The  most  noticeable  feature  is  the  large  belly, 
for  which  the  child  is  brought  to  the  clinic  (Figs.  215  and  216). 


PERITONEAL    TUBERCULOSIS 


601 


Diagnosis  of  fluid  is  made  by  the  usual  signs.  Hepatic  cirrhosis  as 
a  cause  must  be  excluded.  This  is  not  always  easy,  as  perihepatitis 
occasionally  accompanies  this  form,  and  the  stools  may  be  at  times 
crumbly  and  light-colored.  In  the  absence  of  tubercular  manifestations 
elsewhere,  some  of  the  ascitic  fluid  centrifugalized  should  be  examined 
for  bacilli,  or,  better,  injected  into  a  rabbit  or  guinea-pig  as  a  test. 

The  dry  or  plastic  form  shows  little  tendency  to  fluid  accumula- 
tion. The  abdomen  is  flat,  or  distended  with  gas.  Careful  palpation 
may  outline  nodules  and  masses  of  enlarged  glands,  matted  omentum 
and  viscera,  which  are  agglutinated  by  the  profuse  plastic  exudate. 
The  finger  in  the  rectum  may  feel  tubercular  masses  and  bands  of 
adhesion  in  the  lower  bowel,  that  cause  obstruction.    Fecal  masses  must 


Fig.  215.— Boy,  aged  12  years.    Tuberculous  peri- 
tonitis, ascitic  form.    Recovery. 


Fig.  216.— Side  view  of  Fig.  215. 


be  excluded,  as  thorough  evacuation  of  the  bowel  sometimes  changes 
the  abdominal  topography.  Fever,  tenderness  on  pressure,  lancinating 
or  colicky  pains,  wasting,  malaise,  and  diarrhoea,  are  usually  more  pro- 
nounced than  in  the  wet  form.  The  diagnosis  is  made  by  the  presence 
of  nodules  and  chronicity,  and  corroborated  by  other  signs  of  tuber- 
culosis or  history  of  exposure. 

An  intermediate  form  is  encountered  in  which  the  fluid  is  walled 
off  by  adhesions,  giving  atypical  signs  on  percussion  and  palpation, 
which  change  of  posture  does  not  affect.  Rectal  exploration  or  exami- 
nation under  anaesthesia,  after  thorough  cleaning  out  of  the  bowels,  may 
be  necessary,  and  if  fluid  be  located,  aspiration  with  animal  inoculation 
may  be  practised. 


602  THE    SPECIFIC    INFECTIOUS    DISEASES 

The  prognosis  is  fairly  good  in  the  ascitic  form  and  not  necessarily- 
fatal  in  the  plastic.  It  depends,  of  course,  upon  the  evidence  of  gen- 
eral tubercular  infection,  recuperative  power  of  the  individual,  and,  in 
no  small  degree,  upon  the  treatment.  The  disease  is  essentially  chronic, 
although  it  is  occasionally  met  with  in  a  subacute  form.  The  presence 
of  albumin  in  the  urine  increases  the  gravity  of  the  prognosis,  as  sug- 
gestive of  amyloid  degeneration. 

The  local  treatment  of  tuberculous  peritonitis  has  occasioned  much 
discussion.  The  fact  that  a  majority  of  laparotomies  in  the  ascitic 
form  of  this  disease  have  been  survived  has  led  some  surgeons  to 
advocate  the  operation,  although  there  is  no  evidence  to  show  that  the 
transient  exposure  of  the  peritoneum  hastened  reparative  changes  or 
absorption.  Evacuation  of  the  fluid  by  aspiration,  and  absolute  rest 
in  bed,  with  other  appropriate  treatment,  furnishes  as  large  a  per- 
centage of  recoveries  as  the  more  heroic  methods.  Spontaneous  re- 
covery is  not  rare  in  cases  where  the  tuberculous  process  is  restricted 
to  the  peritoneum. 

In  all  abdominal  tuberculosis  the  digestive  function  must  be  pro- 
moted by  all  means,  and  the  pain  and  diarrhoea  controlled  by  opium 
if  necessary.  Application  to  the  abdomen  of  unguentum  Crede,  un- 
guentum  iodoformi  with  ten  per  cent,  lanolin,  or  the  four  per  cent, 
yellow  oxide  of  mercury,  rubbed  up  with  unguentum  belladonnae, 
may  be  applied  and  covered  with  impervious  protective  tissue.  Con- 
centrated proteid  foods  are  essential.  The  bowels  should  be  evacuated 
when  necessary  by  saline  enemata  rather  than  by  purgative  drugs.  The 
general  treatment  for  tuberculosis  must  not  be  neglected. 

GENERAL   TREATMENT  FOR  TUBERCULOSIS. 

Since  no  specific  treatment  for  general  tuberculosis  is  known,  the 
importance  of  prophylaxis  is  obvious.  Our  knowledge  of  the  nature 
of  the  infection  and  its  methods  of  propagation  furnish  us  at  once 
the  key  to  its  prevention.  It  is  not  necessary  to  eat  or  inhale  tuber- 
culous sputa,  either  moist  or  dried,  to  become  infected.  The  vapor 
from  the  lungs  of  a  tuberculous  patient  when  laughing,  coughing,  or 
sneezing,  though  free  from  palpable  sputum,  may  carry  bacilli  whose 
levity  permits  of  prolonged  suspension  in  the  air.  Hence,  personal 
proximity  is  always  dangerous  to  a  susceptible  child.  The  infant 
should  be  immediately  removed  from  a  tuberculous  mother,  nor  should 
children  be  allowed  in  the  same  house  with  a  known  or  suspected  case. 

The  danger  of  tuberculous  infection  is  but  one  of  many  reasons 
why  kissing  and  coddling  of  infants  should  be  forbidden.  Wet  nurses 
and  attendants  should  be  subjected  to  a  careful  examination  by  the 
physician  for  indications  or  history  of  tuberculous  lesions.  Delicate 
children,  and  those  with  family  tendency  towards  tuberculosis,  should 
always  be  put  upon  the  suspected  list  and  supervised  accordingly. 
Nothing  should  be  omitted  to  develop  respiratory  vigor  and  promote 
healthy  metabolism.     The  individual  resistance  must  be  constantly  ap- 


TREATMENT    FOK    Tl'JiKIM  TLOSIS  603 

pealed  to  and  strengthened  by  all  known  means,  such  as  cold  baths,  mas- 
sage, exercise,  etc.,  while  avoiding  exposure  to  possibilities  of  infection. 
Since  most  diseases  of  infancy  and  childhood  predispose  to  tuberculosis, 
all  should  be  treated  with  care,  even  though  known  to  be  self-limited.  In 
fact,  all  influences,  occupations,  or  customs,  whether  domiciliary,  edu- 
cational, or  social,  which  interfere  with  the  fullest  physical  development, 
should  be  corrected. 

All  lesions  of  the  respiratory  tract  which  restrict  free  breathing  or 
favor  infection,  such  as  rhinitis,  tonsillitis,  adenoid  growths,  otitis,  or 
bronchitis,  should  receive  prompt  treatment;  and  all  enlargements  of 
lymph  nodes  must  be  regarded  with  suspicion.  It  seems  hardly  neces- 
sary to  state  that  the  sputum  of  a  tuberculous  person  should  be  promptly 
destroyed,  and  all  articles  in  his  vicinity  frequently  boiled  or  disinfected. 

The  treatment  of  a  tuberculous  child  must  depend  upon  the  indi- 
vidual case  and  nature  of  the  lesions.  A  few  general  principles  only 
may  be  given.  Fresh,  dry  air  and  sunlight  are  the  great  desiderata 
both  in  the  prophylaxis  and  treatment.  In  this  way  change  from  a  damp 
and  variable  climate  to  one  which  is  dry  and  warm,  with  the  maxi- 
mum of  sunshine,  may  be  necessary,  so  that  the  child  may  practically 
live  out  of  doors.  Feeding  is  all-important,  while  guarding  jealously 
the  stomach  and  digestive  tract  from  disorder.  Concentrated  assimilable 
nutrients  must  be  selected, — as  milk,  cream,  proteids,  and  cereals  rich 
in  phosphates.  Stomachics  and  appetizing  bitters  and  tonics,  such  as 
calisaya,  nux  vomica,  and  cinchona  preparations,  are  useful,  and  feeble 
■digestion  may  require  hydrochloric  acid,  pepsin,  pancreatin,  or  the  par- 
tial predigestion  of  food  temporarily. 

Frequent  or  forced  feeding  may  be  advisable,  and  many  cases  require 
the  judicious  use  of  alcoholic  stimulants.  Egg-nog,  or  warm  milk  and 
raw  egg  at  bedtime,  are  usually  indicated. 

Fatiguing  exercise  must  be  avoided;  massage  and  sleeping  or  rest- 
ing in  the  open  air  may  take  its  place.  Enlarged  glands  which  tend 
to  chronicity  should  be  removed,  mucous  lesions  and  carious  teeth 
promptly  treated,  and  the  body  carefully  examined  for  early  signs  of 
l)ony  or  articular  involvement  which,  if  found,  should  receive  attention. 

A  few  drugs,  while  not  specific,  have  won  a  reputation  for  retarding 
the  extension  of  tuberculous  processes  and  promoting  healthy  tissue 
growth.  Cod-liver  oil  and  the  hypophosphites  have  decided  value  when 
judiciously  administered.  Creosote,  or,  better  for  children,  guaiacol  (the 
carbonate),  is  well  borne  and  should  be  given,  five  to  twenty  grains  (0.33- 
1.3  Gm.)  daily  in  broken  doses  every  four  to  eight  hours.  Arsenic  is  of 
value  in  the  form  of  Fowler's  solution,  well  diluted,  after  food,  one  to 
ten  minims  (0.06-0.6  C.c),  care  being  taken  not  to  disturb  the  stomach. 

In  weak  and  rapid  pulse,  digitalis  should  be  given  in  small  doses  and 
may  be  continued  for  weeks,  with  good  results  upon  nutrition  and 
elimination.  If  not  well  borne  by  the  stomach,  strophanthus  or  caf- 
feine may  be  substituted.  Pulmonary  and  other  tuberculous  lesions 
should  receive  appropriate  treatment,  which  is  discussed  elsewhere. 


CHAPTEK    XVI 
DISEASES    OF    THE    SKIN 

PREVALENCE  IN   CHILDHOOD 

The  importance  of  the  skin  as  an  organ  through  its  multiple  func- 
tions of  protection,  respiration,  absorption,  elimination,  secretion,  excre- 
tion, sensation,  and  heat  regulation,  cannot  be  unduly  emphasized. 
Although  much  is  yet  to  be  learned,  enough  is  known  of  the  interde- 
pendence between  these  functions  and  those  of  general  metabolism  to 
lend  importance  to  any  integumentary  disturbance,  whether  structural 
or  functional. 

2t¥ith  a  better  understanding  of  the  complex  processes  of  metabolism, 
it  seems  less  strange  that  skin  changes  have  been  long  regarded  as  indica- 
tive of  constitutional  disorder,  than  that  modern  pathologists  should  try 
to  minimize  this  relationship  by  ignoring  disturbances  of  metabolism  in 
their  search  for  local  causes.  Without  attempting  to  lessen  the  impor- 
tance of  local  causes  for  local  lesions,  many  of  which  are  obvious, 
attention  is  called  to  the  unanimity  of  opinion  among  those  most  familiar 
with  the  disorders  of  infancy,  that  careful  search  rarely  fails  to  find 
adequate  constitutional  cause  for  the  occurrences  and  persistence  of  many 
skin  lesions  in  which  extraneous  influences  merely  act  as  excitants. 

Did  the  importance  of  disturbances  of  metabolism  as  a  factor  in  skin 
disease  need  emphasis,  it  might  be  secured  from  the  fact  that  the  develop- 
ing period,  with  its  tremendous  activity  and  double  burden  of  metab- 
olism, furnishes  the  largest  proportion  and  greatest  variety  of  skin 
disorders. 

This  prevalence  has  been  variously  accounted  for  on  the  ground  that 
the  infant  skin  is  delicate  and  peculiarly  susceptible  to  local  irritation ; 
that  his  helplessness  increases  the  liability  to  trauma,  and  that  immunity 
is  not  yet  secured  to  certain  infections  which  occur  but  once. 

The  first  two  reasons  are  but  half  truths,  for  the  prompt  repair 
of  skin  traumatisms  in  early  life  is  proverbial,  while  the  limitations  to 
locomotion  in  infancy  more  than  offset  the  helplessness  in  the  infrequency 
of  exposure  to  heat,  cold,  sun,  wind,  trauma,  infection,  and  other  extra- 
neous causes  to  which  disorders  of  the  skin  are  due. 

Although  few,  if  any,  skin  lesions  are  confined  exclusively  to  child- 
hood, the  pathology  of  the  developing  period  is  such  as  to  give  to  certain 
skin  diseases  peculiarities  characteristic  of  this  age.  Among  these  may 
be  mentioned  the  skin  lesions  of  congenital  syphilis  in  the  early  months 
of  life,  ichthyosis  (either  congenital  or  as  an  early  childhood  affection), 
impetigo  contagiosa,  ringworm,  scabies,  and  pediculosis  common  in  the 
school  age.  The  erythemas  and  the  greater  frequency  of  rashes  from 
604" 


ERYTHEMA— SEBORRHEA  605 

obscure  infections,  and  urticaria  from  indigestion,  with  eczema  in  its 
protean  forms,  find  their  most  favorable  field  in  the  integument  of 
children  in  the  first  five  years  of  life. 

ERYTHEMA   SIMPLEX    ( REDNESS   OF   SKIN). 

From  anatomical  and  physiological  reasons  hypersemia  is  readily 
induced  in  the  delicate  skin  of  infancy  and  childhood.  The  varieties  of 
erythema  are  almost  as  numerous  as  the  causes  which  lead  to  the  con- 
dition. Anything  which  induces  unusual  determination  of  blood  to  the 
superficial  capillaries,  may  cause  an  erythema,  while  paresis  of  the 
arterioles  or  obstruction  to  the  efferent  circulation  may  be  responsible 
for  its  persistence.  The  skin  may  be  reddened  from  the  local  action  of 
irritants, — as  mustard,  acrid  secretions  from  plants,  local  traumatism, 
heat,  reaction  from  cold,  or  retained  secretions  in  the  folds  of  the  integu- 
ment. Erythema  is  the  most  common  accompaniment  of  fever,  auto- 
intoxication, and  derangements  of  the  circulation,  either  from  nervous 
or  mechanical  causes.  The  internal  administration  of  certain  drugs — 
as  belladonna,  quinine,  chloral,  and  diphtheria  antitoxin — may  give  rise 
to  general  or  local  erythema.  The  vicinity  of  superficial  wounds  or 
ulcers  may  show  extensive  erythema  and  infiltration  which  is  frequently 
mistaken  for  erysipelas. 

The  prognosis  and  treatment  of  symptomatic  erythema  are  those  of 
the  determining  conditions. 

The  erythema  from  local  irritants — one  of  the  best  examples  of  which 
is  seen  in  the  intertrigo  of  neglected  infants  from  long  contact  with 
soiled  diapers — needs  treatment,  lest  the  process  develop  a  true  eczema, 
a  common  sequel.  Cleanliness  alone  will  often  suffice,  but  obstinate 
cases,  especially  where  digestive  disturbances  or  acrid  urinary  and  fecal 
discharges  tend  to  keep  up  the  irritation,  require  topical  application. 
Diapers  not  thoroughly  rinsed  after  being  washed  with  strong  soap  or 
alkaline  solutions,  may  cause  scalding  of  the  buttocks,  although  fre- 
quently changed  and  wet  only  with  bland  urine. 

In  addition  to  the  correction  of  indigestion  and  acrid  discharges,  the 
reddened  area  should  be  dusted  with  a  bland  powder  (Formula  28  or  29). 
Obstinate  cases  may  require  the  protection  of  a  soothing  ointment  like 
oxide  of  zinc  and  vaseline  or  bismuth  and  castor  oil. 

SEBORRHCEA. 

Seborrhea  is  due  to  an  abnormal  activity  of  the  sebaceous  glands, 
the  discharged  products  of  which  collect  upon  the  cutaneous  surface  in 
the  form  of  an  oily  exudate  (seborrhcea  oleosa),  or  of  dry  friable  crusts 
or  scales  {seborrhcea  sicca).  The  disorder  usually  occurs  in  infancy  as 
seborrhcea  capitis.  It  appears  on  the  vertex,  especially  over  the  anterior 
fontanelle,  in  thin,  dry,  dirty-yellowish  scales  ("milk  crust"),  which 
may  adhere  quite  firmly  to  the  scalp.  It  may  cover  the  entire  head 
and  even  involve  the  eyebrows.  Gentle  removal  shows  the  scalp  pale  or 
slightly  hyperamiic,  but  devoid  of  inflammation.     Though  patches  of 


606  DISEASES    OF    THE    SKIN 

seborrhoea  may  appear  upon  the  head  of  an  apparently  healthy  infant, 
the  abnormal  activity  of  the  sebaceous  glands  is  usually  associated  with 
conditions  of  disordered  nutrition,  and  may  be  seen  in  obstinate  form 
on  the  scalp  of  the  poorly  nourished  bottle-fed  baby.  In  older  children 
it  appears  in  the  form  of  dandruff,  which  collects  in  little  heaped-up 
masses  around  the  orifices  of  the  sebaceous  ducts  and,  if  persistent, 
causes  itching  and  loss  of  hair. 

The  prognosis  of  seborrhoea  capitis  is  good,  as  it  usually  disappears 
after  the  nursing  period,  but  it  may  recur  with  the  various  disturbances 
of  the  general  nutrition.  Misguided  efforts  at  the  removal  of  these 
scales  by  anxious  mothers  cause  persistency  of  the  seborrhea  and  fre- 
quently result  in  traumatism  and  infection.  If  the  crusting  be  thick  or 
extensive,  decomposition  of  the  deeper  layers  may  lead  to  true  eczema 
capitis, — hence  the  need  for  early  treatment  in  every  case. 

Aside  from  attention  to  general  nutrition  and  hygiene  the  treatment 
is  local  and  consists  in  the  gentle  removal  of  the  scales  and  crusts.  This 
may  be  accomplished  only  after  prolonged  maceration  with  oil.  "Warm 
olive  or  almond  oil  should  be  freely  applied  over  the  affected  area  twice 
daily,  and  the  head  covered  with  a  cap  of  muslin  or,  preferably,  rubber 
tissue. 

Applications  for  several  days  may  be  necessary  before  the  macer- 
ated crusts  will  yield  to  the  gentle  application  of  warm  water  and  castiie 
soap,  and  the  process  may  require  several  repetitions.  Since  removal  of 
the  crusts  does  not  diminish  the  seborrhoea,  the  head  should  be  gently 
shampooed  once  a  week  with  superf  atty  soap,  with  the  application  every 
two  to  four  days  of  an  ointment  of  sulphur  and  vaseline  (1:50),  or 
salicylic  acid  and  vaseline  (1 :  100).  The  use  of  the  fine  comb  and  strong 
alkaline  soap  should  be  avoided. 

Seborrhoea  in  other  parts  of  the  body — such  as  the  umbilicus,  pre- 
puce, and  vulva — is  sometimes  troublesome,  the  excessive  secretion  under- 
going decomposition  with  subsecpient  inflammation  of  the  parts.  The 
treatment  is  cleanliness,  and  the  application  of  weak  solutions  of  alum 
and  tannin. 

ECZEMA. 

No  definition  of  eczema  may  be  given  which  will  embrace  all  forms, 
as  no  one  characteristic  lesion  is  common  to  all.  In  the  majority  of  cases 
there  is  an  inflammation  of  the  superficial  layers  of  the  skin  accompanied 
by  congestion,  infiltration,  exudation,  transudation,  and  pruritus,  with 
resultant  papules,  vesicles,  pustules,  and  the  formation  of  crusts,  scabs, 
and  ulcers.  Several  or  all  of  these  processes  may  appear  concurrently 
or  consecutively  over  a  given  area  of  the  skin. 

The  disease  is  very  common,  representing  in  frequency  one-third  of 
all  skin  disorders.  Of  many  thousands  of  tabulated  cases  of  eczema, 
one-fourth  were  found  in  children  under  five  years  of  age. 

As  to  the  cause  of  eczema  the  dermatologists  are  still  divided,  some 
holding  that  it  is  a  specific  parasitic  disease ;  others  regard  it  as  a  poly- 
morphic inflammation  of  the  skin  due  to  some  undefined  condition  of 


ECZEMA  607 

constitutional  debility.  Many  speak  of  an  eczeiiiatous  dyserasia  of 
which  the  various  skin  lesions  are  but  a  few  of  the  manifestations. 
Again,  others  question  the  entity  of  such  a  disease  as  eczema,  claiming 
that  its  symptom  complex  is  made  up  of  many  heterogeneous  skin  dis- 
orders caused  by  a  variety  of  unrelated  conditions. 

The  pediatric  clinician  will  be  slow  to  accept  any  theory  which  fails 
to  give  etiologic  prominence  to  dyserasia,  autointoxication,  and  other 
constitutional  conditions. 

Among  the  exciting  causes  may  be  mentioned  extremes  of  heat  and 
cold,  sudden  changes  of  temperature,  the  drying  effects  of  wind  and 
sun,  maceration  from  prolonged  moist  contact,  excessive  perspiration, 
accumulation  of  dirt  and  secretions,  neglected  seborrhcea,  the  too  stren- 
uous efforts  at  cleanliness,  strong  soaps,  rancid  cosmetics,  rough  clothing, 
especially  coarse  woollens,  animal  parasites, — especially  the  pediculus 
capitis  and  any  mechanical  or  chemical  local  irritant.  It  is  claimed  that 
a  careful  study  of  any  case  of  eczema  in  childhood  will  bring  to  light 
some  error  in  diet  or  disturbance  of  digestion. 

Excess  of  fats,  proteids,  or  carbohydrates,  especially  oatmeal  and 
potatoes,  is  known  to  promote  eczematous  outbreaks,  while  a  gouty  his- 
tory is  very  commonly  associated  with  this  disease. 

Whatever  be  the  primary  exciting  cause,  the  local  lesions,  especially 
if  moist,  soon  become  infected  with  pyogenic  and  other  micro-organisms 
which  add  variety  and  chronicity  to  the  morbid  processes,  with  resultant 
destruction  or  hyperplasia  of  various  tissue  elements.  That  the  pru- 
ritus and  discomfort  react  upon  nutrition  is  not  only  theoretically  prob- 
able but  clinically  obvious,  so  that  a  vicious  circle  increases  the  obstinacy 
of  the  disease. 

Common  features  are  itching  and  burning.  Excoriation  from  scratch- 
ing is  a  prolific  cause  of  its  continuance.  A  number  of  adjectives  are 
used  to  describe  its  protean  forms,  but  clinically  the  disease  may  best  be 
described  as  acute,  subacute,  and  chronic. 

The  eczemas  of  childhood  are  usually  of  an  acute  inflammatory  type 
with  recurrences  which  may  lead  to  chronicity,  although  self -limitation 
of  the  disease  is  the  rule.  The  affection  as  seen  in  sucklings  shows  a 
tendency  to  recovery  before  the  end  of  first  dentition  and  early  eczema 
rarely  persists  beyond  the  fifth  year. 

The  favorite  seat  of  infantile  eczema  is  the  scalp  and  face,  where  it 
appears  in  recurrent  attacks  in  the  form  of  eczema  rubrum,  so  called 
from  its  red,  raw  appearance.  This  form,  beginning  as  a  circumscribed 
area  of  coalescing  papules  or  vesicles,  spreads  by  gradual  radiation  to 
adjacent  surfaces.  Later  it  shows  areas  denuded  of  epidermis,  from 
which  thin  serum  oozes  and  dries  upon  the  surface  like  varnish,  causing 
intolerable  pruritus.  Adjacent  vesicles  may  break  down  and  become 
infected  with  pyogenic  cocci  and  form  crusts  and  scabs,  beneath  which 
the  pus  is  confined,  constituting  the  ulcerative  variety. 

A  pre-existing  seborrhcea  capitis  affords  beneath  its  thickened  crusts 
good  facilities  for  the  development  of  papular,  vesicular,  and  pustular 


608  DISEASES    OF    THE    SKIN 

forms.  Enlargement  of  the  lymph-nodes  in  the  vicinity  of  persistent 
eczeniatous  lesions  is  not  uncommon. 

While  infiltration  of  the  skin  is  a  feature  of  the  subacute  and  chronic 
forms,  the  large  areas  of  leathery  integument  seen  in  adults  is  not 
common  in  childhood. 

A  more  chronic  type  varies  from  groups  of  discrete  or  coalescent 
flat  papules,  to  circumscribed,  scaly,  hyperaemic  areas  which  may  simu- 
late nearly  every  known  form  of  dry  dermal  lesions. 

Diagnosis. — The  recognition  of  eczema  in  children  is  usually  not 
difficult.  It  is  the  cause  which  is  frequently  obscure.  Its  location  upon 
the  face  and  scalp  is  characteristic  in  infancy.  If  lesions  occur  at  the 
nucha  or  on  the  occipital  scalp,  pediculi  or  their  ova  will  usually  be 
found.  Papular  lesions  upon  the  buttocks  and  around  the  anus  may 
resemble  syphilides  and  specific  mucous  patches.  However,  syphilitic 
lesions  do  not  itch,  but  show  copper-colored  areas  and  corroborative 
lesions  in  other  parts,  especially  upon  the  palms  and  soles,  with  splenic 
enlargement,  cachexia,  and  history  of  ' '  snuffles. ' ' 

Scabies  with  its  multiform  lesions  rarely  involves  the  scalp.  It  is 
first  seen  in  areas  of  thin  skin  where  its  cuniculi  may  be  demonstrated 
with  a  moderate  magnifier,  gives  a  history  of  infection,  and  yields 
promptly  to  treatment. 

Prognosis. — The  obstinacy  of  eczema  is  to  be  expected  from  the  mul- 
tiplicity and  nature  of  its  causes.  Its  early  subjugation  is  dependent 
upon  the  recognition  and  removal  of  the  cause.  This  means  careful 
diagnosis,  and  faithful  co-operation  on  the  part  of  the  mother  or  nurse, 
hence  no  general  prognosis  is  possible.  Unfortunately,  the  routine 
methods  of  treatment  by  favorite  formulae  with  indifferent  adaptation 
to  the  requirements  of  the  special  case,  has  made  of  eczema  an  unjus- 
tifiable bugbear.  The  utterance  of  a  well-known  clinician — that  "the 
practitioner  is  lucky  who  happens  to  be  treating  an  eczema  when  it 
happens  to  get  well" — is  the  outgrowth  of  the  general  misconception 
of  the  requirements  of  diagnosis  and  treatment,  and  the  lay  tendency  to 
hawk  the  case  from  clinic  to  clinic  in  search  of  a  quick  specific  cure. 

Treatment. — As  before  stated,  careful  scrutiny  of  eczema  in  a  child 
will  usually  reveal  some  underlying  cause  or  predisposition.  It  is  true 
that  the  disease  may  have  become  chronic  through  neglect,  although  the 
primary  cause  has  long  since  disappeared. 

Obviously,  then,  gastro-intestinal  disorders,  if  present,  should  receive 
careful  attention  according  to  requirements.  So,  too,  any  catarrhal 
process  or  organic  disturbance  should  be  carefully  treated.  It  should 
be  borne  in  mind  that  perversion  of  metabolism  and  morbid  products 
of  disassimilation  are  frequently  unaccompanied  by  gross  evidences  of 
dyspepsia.  The  child  may  be  apparently  well  nourished  according  to 
the  standard  of  growth  and  weight,  and  the  earliest  evidences  of  auto- 
intoxication may  be  this  very  predisposition  to  inflammatory  lesions 
of  the  skin. 

It  is  common  to  attribute  an  eczematous  intertrigo  to  the  irritating 


ECZEMA  609 

discharges  of  bowels  and  kidneys  as  an  exciting  cause.  It  is  less  common 
to  regard  the  condition  of  bowels  and  kidneys  eliminating  this  acrid 
material  as  expressive  of  the  predisposing  cause.  Renal  insufficiency,  as 
in  the  gouty  diathesis,  means  integumentary  insufficiency  as  an  elimi- 
nating organ. 

Eczema  of  the  acute  inflammatory  or  highly  congestive  type,  common 
in  infancy,  needs  eliminatives,  such  as  small  doses  of  calomel,  with  mod- 
erately full  doses  of  bicarbonate  of  soda.  This  treatment  should  be 
alternated  with  alkaline  diuretics — acetate  or  citrate  of  potassium — 
with  a  free  supply  of  water. 

In  eczema,  the  skin,  like  any  other  diseased  organ,  should  be  given 
rest  from  excessive  elimination  by  the  above-described  measures,  and  by 
reduction  of  the  quantity  of  food  ingested,  especially  the  proteids  and 
carbohydrates.  In  bottle-fed  babies  the  casein  should  be  diminished. 
Older  children  should  be  given  less  meat,  and  oatmeal  and  potatoes  may 
be  profitably  reduced  or  withheld  for  a  time. 

Hyperemia  and  the  perverted  function  of  the  skin  may  also  be 
reduced  in  older  children  by  putting  them  to  bed.  This  also  secures 
relief  from  the  irritation  of  clothing  and  affords  a  better  opportunity 
for  thorough  topical  treatment. 

In  the  main,  the  purpose  of  local  treatment  is  twofold, —  (1)  relief  of 
irritation,  (2)  protection  from  infection.  Incidentally  it  may  be  neces- 
sary to  free  the  parts  from  desiccated,  inflammatory  debris,  for  which 
purpose  olive  oil,  plain  or  carbolized  (one  per  cent.)  may  be  used,  or  a 
bran  poultice,  sterilized  by  thorough  cooking,  may  be  employed.  The 
parts  once  cleansed,  bland  applications  like  oxide  of  zinc,  either  in  the 
form  of  ointment  with  vaseline  (1:8),  or  as  a  lotion  with  lime-water 
(1:  5),  may  be  made  on  aseptic  lint  or  gauze. 

Three  sources  of  irritation  must  be  constantly  guarded  against, — 
air,  water,  and  finger  nails.  The  nails  must  not  only  be  cut  short,  but 
the  child's  hands  should  be  muffled  or  even  confined  by  the  outer  gar-r 
ment,  or  a  bandage,  if  necessary.  This  is  a  detail  of  special  importance, 
as  an  unguarded  moment  may  undo  the  work  of  days  of  therapy.  The 
face  and  head  should  be  protected  by  a  mask  of  firm  muslin  in  which 
holes  are  cut  for  the  eyes,  nose,  mouth,  and  ears.  This  mask  will  serve 
also  to  retain  the  dressings  over  the  affected  surfaces,  which  should  be 
changed  as  often  as  they  become  dry. 

For  the  zinc  ointment  Lassar's  paste  may  be  substituted,  thickly 
applied  on  muslin  or  linen  as  affording  greater  relief  from  the  intolerable 
pruritus.  It  may  be  necessary  to  administer  hypnotics  temporarily  to 
secure  the  needed  rest, — as  bromides,  sulphonal,  or  trional.  Chloral 
hydrate  and  opium  are  contraindicated. 

Exuding  surfaces  are  sometimes  best  protected  by  a  varnish  of 
gelatin  and  oxide  of  zinc  (Formula  32). 

Impetiginous  ulcers  must  be  cleansed  from  pus  and  products  of 
decomposition  by  irrigation  with  boric  acid  solution  or  peroxide  of 
hydrogen.     The  application  of  nitrate  of  silver  may  prove  valuable,  as 

39 


610  DISEASES    OF    THE    SKIN 

indolent  lesions  with  chronic  infiltration  of  tissues  require  gentle  stimu- 
lation. 

Applications  of  tar,  Peruvian  balsam,  unguentum  hydrargyri  ammo- 
niati,  and  sulphur  are  favorites  with  many,  but  the  particular  remedy 
is  of  less  importance  than  that  it  should  fulfil  the  indications  by  being 
mildly  stimulating,  astringent,  antiseptic,  and  nonirritating. 

The  same  principles  of  treatment  apply  to  eczema  in  other  portions 
of  the  body.  The  ingenuity  of  the  attendant  is  often  taxed  to  provide 
means  of  retention  and  prevent  traumatisms  and  excoriations  from 
scratching.  Necessary  cleansing  ablutions  may  be  made  with  nonirri- 
tating, superfatty,  or  tar  soaps,  or  bran  water. 

MILIARIA. 

Miliaria  is  an  affection  of  the  skin  due  to  the  obstruction  of  the  ducts 
of  the  sudoriparous  glands,  from  congestion  of  the  cutaneous  vessels  and 
from  exudation  around  the  duct.  It  is  closely  associated  with  hyperemia 
of  the  skin. 

The  lesions  may  be  inflammatory  or  noninflammatory.  To  the  former 
belongs  the  papular  eruption  known  as  prickly  heat,  lichen  tropicus, 
strophulus,  or  red  gum.  In  infancy  and  childhood  this  form  may  appear 
on  any  part  of  the  body.  It  is  invariably  associated  with  exposure  to 
high  temperature  or  too  heavy  clothing.  It  frequently  develops  in 
infants  during  the  first  few  days  of  life,  and  aside  from  heat  is  associated 
with  rough  clothing  or  irritating  applications  to  the  skin. 

The  commonest  lesions  are  small,  discrete,  dark  red  papules  upon  an 
erythematous  skin.  These  occasion  great  discomfort  and  insomnia  from 
an  intense  prickling  or  burning.  Some  of  the  papules  may  quickly 
become  vesicular  or  even  pustular,  while  the  scratching  frequently  pro- 
duces traumatic  lesions  which  may  become  infected. 

The  noninflammatory  variety,  miliaria  crystalline/,  (sudamina),  ap- 
pears as  a  profuse,  discrete  eruption  of  vesicles  which  glisten  from  the 
transparency  of  their  contents.  They  resemble  minute  drops  thickly 
studding  a  normal  skin.  Efforts  to  wipe  these  off  reveal  the  fact 
that  they  are  minute  transparent  vesicles  upon  a  non-inflamed  base. 
They  do  not  rupture  but  disappear  by  absorption,  leaving  rarely  a 
slight  scaly  desquamation.  Occasionally  the  fluid  contents  becomes 
slightly  opaque  (miliaria  alba),  in  which  case  the  desquamation  is  more 
noticeable. 

Both  forms  may  accompany  profuse  perspiration  from  any  cause, 
and  are  not  uncommon  in  debilitated  children,  after  the  crises  of  acute 
fevers,  and  during  convalescence  from  typhoid.  These  papules  or  vesicles 
last  from  one  to  four  or  five  days,  but,  with  continuation  of  the  cause, 
successive  crops  appear. 

The  diagnosis  from  papular  eczema  is  made  by  the  sudden  develop- 
ment and  transient  character  of  the  rash,  which  is  discrete  and  not 
attended  by  infiltration  or  oozing.  From  the  persistent,  flattened  non- 
irritable  syphilides,  miliaria  should  be  easily  distinguished.     Sudaminal 


URTICARIA  fill 

vesicles  differ  from  those  of  varicella  in  the  smaller  size,  greater  pro- 
fusion, and  absence  of  areolae  and  constitutional  symptoms. 

A  miliary  rubra,  complicated  by  an  acute  cold,  may  resemble  a  mild 
attack  of  measles.  The  progress  and  distribution  of  the  eruption,  and 
the  presence  of  Koplik's  spots,  would  decide  the  diagnosis.  Rotheln 
occur  in  epidemics  and  usually  give  a  history  of  exposure.  Children 
should  not  be  compelled  to  wear  heavy  woollens  in  hot  weather,  and 
when  light  flannels  irritate,  muslin  or  linen  may  be  interposed.  Fre- 
quent cool  bathing,  and  free  dusting  of  the  affected  surface  with  some 
drying  powder  (Formula  28  or  29),  will  relieve  the  irritation.  Profuse 
sweating  may  be  modified  by  applications  of  weak  solutions  of  alum  or  of 
eupric  sulphate  (1  :  300). 

URTICARIA — NETTLE    RASH  ;    HIVES. 

Urticaria  in  infancy  and  childhood  is  so  commonly  associated  with 
disorders  of  the  digestive  tract  that  it  has  come  to  be  regarded  as  a 
symptom  of  indigestion.  Even  when  apparently  induced  by  external 
influences — such  as  sudden  change  in  temperature,  removal  of  clothing 
in  a  cold  room,  or  scratching,  induced  by  bites  of  insects — the  unusual 
appearance  of  wheals  and  raised  blotches  calls  attention  to  the  state  of 
the  child's  digestion.  There  is  usually  found  a  furred  tongue,  bad 
breath,  some  elevation  of  temperature,  flatus,  and  later  foul  stools,  with 
a  frequent  history  of  palpable  errors  in  diet. 

An  undoubted  predisposition  to  skin  symptoms  of  indigestion  exists 
in  certain  children,  usually  those  of  neurotic  or  gouty  parentage.  Every 
boy  of  the  older  days,  when  the  rod  ruled  in  school  and  "lap  jacket" 
was  a  common  pastime  on  the  playground,  recalls  the  diathesis  for  wheals 
and  welts  from  slight  irritation  of  the  skin  in  some  children  and  its  total 
absence  in  others. 

The  list  of  dietary  articles  reported  to  have  caused  urticaria  is  a 
long  one.  The  most  familiar  are  fish,  oysters,  lobsters,  crabs,  straw- 
berries, buckwheat-cakes,  pastry,  mushrooms,  pork,  cucumbers,  and  even 
eggs  and  milk  in  susceptible  individuals.  The  ingestion  of  certain  drugs 
■ — such  as  quinine,  chloral,  hyoscyamus,  copaiba,  and  valerian,  also  the 
use  of  antitoxin — are  known  to  give  rise  to  urticarial  wheals.  Urticaria 
is  also  regarded  as  one  of  the  symptoms  of  worms. 

In  infancy  and  childhood,  although  urticaria  may  consist  only  of  an 
outbreak  of  evanescent  wheals  which  disappear  in  from  a  few  minutes 
to  a  few  hours,  it  not  infrequently  produces  a  more  permanent  type  of 
lesion. — as  papules,  vesicles,  and  even  small  bullae.  Pustulation  occa- 
sionally follows,  and  scratching  and  infection  may  result  in  ulceration. 

A  curious  relationship  is  occasionally  observed  between  urticaria  and 
respiratory  disturbances,  as  attacks  of  cough  and  dyspnoea,  asthmatic 
in  character,  occasionally  accompanying  or  alternating  with  the  lesions 
of  the  skin.  Wheals  are  also  seen  upon  the  nasal,  oral,  and  faueial 
mucosa,  and  swelling  of  the  epiglottis  may  sometimes  endanger  life  from 
obstructed  respiration.    The  respiratory  and  gastric  disturbances  are  sug- 


612  DISEASES    OF    THE    SKIN 

gestive  of  an  urticarial  enanthema  from  which  no  mucous  tract  may  be 
exempt.  Vomiting,  hsematemesis,  diarrhoea,  and  hematuria,  in  addition 
to  the  above-mentioned  symptoms,  have  all  been  reported  in  corrobora- 
tion of  this  theory. 

As  wheals  are  the  common  sign  of  urticaria,  so  pruritus,  tantalizing 
and  insatiable,  is  the  common  symptom.  Scratching  not  only  fails  to 
give  relief  but  may  induce  the  outbreak  of  wheals  upon  the  susceptible 
skin  (urticaria  factitia). 

Prognosis. — The  disorder  is  not  dangerous  to  life  save  in  the  respira- 
tory obstruction  above  mentioned.  In  prolonged  and  frequent  recurrent 
attacks  (chronic  form)  the  loss  of  sleep  and  systemic  disturbance  may 
affect  the  general  health.  In  children  the  attack  is  usually  acute  and 
generally  yields  to  treatment  very  promptly. 

Treatment. — Removal  of  some  of  the  causes  may  be  effected  by  empty- 
ing the  stomach  and  bowels  and  promoting  elimination  from  the  blood 
of  imperfectly  oxidized  products  of  digestion.  Castor  oil,  calomel,  or 
saline  cathartics  are  indicated  and  prompt  emesis  may  be  advisable  if 
unusual  food  has  been  recently  ingested.  Sodium  or  potassium  bicarbo- 
nate, in  full  and  repeated  doses,  are  generally  useful.  Avoidance  of 
anusual  articles  of  food,  especially  those  known  to  cause  an  eruption  in 
susceptible  children,  is  but  a  dictate  of  common  sense. 

For  the  pruritus,  alkaline  lotions  are  useful, — such  as  sodium  or 
potassium  bicarbonate,  sodium  biborate,  and  dilute  aqua  ammonia. 
Dilute  alcohol,  spirits  of  Cologne,  Florida  water,  domestic  vinegar, 
dilute  acetic  or  nitric  acid,  or  a  solution  of  menthol  in  water  (1  :  200), 
have  all  been  found  effective.  Carbolic  acid  in  glycerin  and  water  (one 
or  two  per  cent,  strength)  or  a  few  drops  of  chloroform  or  ether  in  dilute 
alcohol,  are  also  used  with  benefit.  The  skin  must  not  be  rubbed.  The 
medicaments  must  be  applied  by  daubing  with  a  pledget  of  cotton  or, 
better,  by  atomization. 

Vesicular,  pustular,  and  ulcerative  lesions  should  be  treated  like 
similar  lesions  of  eczema  or  impetigo,  either  of  which  disorders  may  be 
complicated  by  urticaria. 

IMPETIGO    CONTAGIOSA. 

Impetigo  contagiosa  is  a  disease  of  the  skin  characterized  by  discrete, 
vesiculo-pustular  lesions  which  quickly  form  crusts.  As  the  name  im- 
plies, it  is  contagious.  Although  most  frequently  seen  in  children  it 
may  affect  adult  members  of  the  family.  While  undoubtedly  contagious, 
no  specific  organism  has  been  isolated  which  fulfils  all  the  etiologic 
requirements.  Strepto-  and  staphylococci  have  been  found,  conjointly 
and  separately,  in  both  ruptured  and  unruptured  vesicles. 

The  favorite  seat  of  the  lesion  is  the  lower  face,  whence  it  may  extend 
by  autoinoculation  by  scratching  to  the  more  accessible  parts  of  the 
head,  trunk,  and  limbs.  Hence,  it  is  rarely  found  upon  the  back.  A 
form  of  stomatitis  has  been  described  in  connection  with  this  affection 
too  frequently  for  mere  coincidence. 


HERPES  613 

Lesions  of  the  conjunctiva  and  vulvar  mucosa  also  have  heen  reported 
as  co-existent  with  impetigo  and  were  probably  of  common  origin. 

The  early  lesion  appears  as  a  small,  flat,  flaccid  vesicle,  the  centre  of 
which  is  depressed  as  the  periphery  extends  and  becomes  pustular. 
Undisturbed,  it  may  attain  the  size  of  a  split  pea  or  even  a  dime,  occa- 
sionally showing  a  transient  areola.  The  contents  exude,  forming  a 
yellowish  crust  which  stands  out  sharply  upon  the  surrounding  healthy 
skin  and  falls  off  at  the  end  of  a  week  or  two,  leaving  only  ;i  slighlly 
reddened  area  which  soon  assumes  a  normal  tint.  Where  a  number  of 
lesions  are  closely  situated  the  crusts  coalesce  and  form  irregular  patches, 
especially  over  the  chin  and  around  the  angles  of  the  mouth.  The  pru- 
ritus, although  not  intense,  is  sufficient  to  cause  scratching,  whereby  the 
characteristic  lesions  are  distorted,  the  crusts  darkened  with  blood,  and 
occasionally  deep  ulcers  induced.  Meanwhile,  fresh  lesions  are  estab- 
lished by  autoinoculation,  so  that  the  patient  often  presents  a  variety 
of  lesions  in  all  the  different  stages  of  development.  Enlargement  of 
the  lymph  nodes  which  drain  the  areas  involved  is  common,  as  in  other 
purulent  infections  of  the  skin.  The  frequency  of  the  disease  in  the 
dispensary  class  of  patients  may  be  accounted  for  partly  by  the  crowded 
condition  of  their  homes,  which  favors  contagion,  and  partly  from  lack 
of  cleanliness,  which  promotes  extension  of  the  lesions. 

Impetigo  contagiosa  may  complicate  any  other  disease,  hence  it  is 
not  infrequently  associated  with  eczema,  pediculosis,  scabies,  and  occa- 
sionally with  syphilis. 

The  diagnosis  is  made  from  the  history,  other  members  of  the  family 
or  associates  showing  similar  lesions.  There  is  rarely  the  intense  itch- 
ing of  eczema,  the  extension  is  by  inoculation,  and  not  by  contiguity 
as  in  the  latter  disease,  and  the  crusts,  even  when  picked  off,  leave  an 
entire,  healthy  skin  instead  of  the  moist,  inflamed  surface  of  eczema. 
The  early  vesicles  of  varicella  are  full  and  tense  and  are  usually  accom- 
panied by  some  fever  and  malaise,  and  dry  down  quickly  into  thin 
flat  scabs. 

Treatment. — The  characteristic  lesions  being  self-limiting,  ordinary 
cleanliness  and  abstinence  from  scratching  should  bring  the  disorder  to  a 
termination  in  a  week  or  ten  days.  The  customary  treatment,  in  addition 
to  bathing  and  change  of  clothing,  consists  in  antiseptic,  soothing  appli- 
cations, such  as  boric  acid  and  lanolin  (1:10),  after  removal  of  the 
crusts  with  castile  coap  and  hot  water.  Extensive  lesions  are  well 
treated  by  daily  applications  of  citrine  ointment  or  one  composed  of 
hydrargyrum  ammoniatum  and  unguentum  zinci  oxidi   (1:40). 

HERPES. 

Herpes  is  a  name  applied  to  an  eruption  of  vesicles  surrounded  by 
a  narrow  area  of  inflammation,  usually  occurring  in  clusters.  From  the 
location  the  disorder  is  called  herpes  labialis,  herpes  facialis,  herpes 
frontalis,  herpes  zoster,  zona,  or  shingles.  Discrete  or  grouped  herpetic 
vesicles  may  occur  on  any  portion  of  the  skin  or  mucous  membrane  and 


614  DISEASES    OF    THE    SKIN 

frequently  show  irregular  linear  distribution  along  the  course  of  a  nerve 
trunk. 

Zoster  is  a  term  used  to  distinguish  herpetic  lesions  which  follow 
the  course  of  a  large  nerve,  and  are  presumably  due  to  a  peripheral  or 
spinal  neuritis.  The  true  etiology,  however,  is  still  in  doubt.  It  is  an 
interesting  fact  that  it  rarely  occurs  a  second  time  in  the  same  individual. 
It  is  usually  preceded  and  accompanied  by  stinging  and  burning  pains 
over  the  affected  area,  also  by  some  fever  and  malaise.  In  childhood, 
however,  the  neuralgia  is  infrequent  and  rarely  severe  after  the  eruption 
has  appeared.  The  appearance  of  zoster  is  that  of  an  irregular  suc- 
cession of  groups  of  vesicles,  which  upon  the  trunk  are  unilateral  and 
extend  from  the  spinal  region  along  the  course  of  a  rib.  The  vesicles, 
at  first  clear  and  more  or  less  discrete,  tend  to  coalesce  while  their  con- 
tents become  at  first  milky  and  later  purulent.  If  undisturbed  they 
soon  form  scabs  which,  falling  off,  leave  the  skin  slightly  reddened  with- 
out permanent  cicatrices.  The  process  is  usually  complete  in  from 
four  to  seven  days. 

Herpes  facialis,  the  favorite  site  of  which  is  upon  the  lips  or  about 
the  angles  of  the  mouth,  is  a  common  accompaniment  of  acute  febrile 
conditions,  especially  those  in  which  the  pulmonary  tract  is  involved. 
It  is  rarely  absent  in  cerebrospinal  meningitis  and  may  accompany  the 
high  temperature  of  malaria  and  pyasmia.  Exposure  to  a  raw  wind,  or 
even  wetting  the  feet,  may  give  rise  to  the  ordinary  ' '  cold  sore. ' ' 

The  lesions  of  herpes  simplex  are  attended  by  only  a  slight  degree 
of  pain.  They  change  quickly  from  vesicles  to  pustules,  forming  scabs 
which,  from  their  location,  are  subject  to  maceration  by  saliva.  They 
may  crack  deeply  and  bleed,  producing  in  some  instances  obstinate  sores. 
Usually,  however,  the  crusts  fall  off  and  the  skin  returns  to  normal  in 
a  week. 

The  treatment  of  all  forms  of  herpes  consists  in  allaying  irritation 
and  preventing  rupture  of  the  vesicles.  For  zoster,  thick  compresses 
wet  with  alcoholic  solution  of  camphor  and  menthol  (two  per  cent,  of 
each),  bound  tightly  about  the  chest,  fulfil  the  indications.  For  pain 
or  restlessness  Dover's  powder  or  codeine  may  be  necessary.  "Cold 
sores"  on  the  face  may  be  treated  at  their  inception  by  the  frequent 
application  of  spirits  of  camphor.  Deep  fissuration  of  the  crusts  may 
be  obviated  by  unguentum  aqua?  rosas  or  unguentum  zinci  oxidi. 

TINEA   TRICHOPHYTINA — RINGWORM. 

Kingworm  is  a  parasitic  disease  due  to  the  trichophyton  fungus  and 
other  varieties  of  fungi  which  attack  the  skin,  hair,  and  nails.  Accord- 
ing to  its  location  it  is  known  as  (1)  tinia  corporis  or  circinata ;  (2)  tinea 
capitis  or  tonsurans,  and  (3)  tinea  unguium  or  onychomycosis. 

The  micro-organism  may  be  transferred  from  one  individual  to 
another  by  personal  contact,  so  that  barber 's-itch  in  the  father  may  be 
responsible  for  tinea  circinata  and  tonsurans  in  mother  or  child.  A 
number  of  domestic  animals  are  known  to  be  subject  to  infection  by  this 


RINGWORM  615 

fungus,  so  that  these  sources  must  be  reckoned  with  in  the  search  for 
origin  in  a  given  case.  Epidemics  of  this  disease  occur  in  schools  and 
institutions  where  many  children  are  brought  into  close  contact. 

The  first  is  not  uncommon  among  school  children  and  the  lasl  men- 
tioned, which  is  of  rarer  occurrence,  may  be  seen  throughout  advanced 
life.  Tinea  capitis  is  essentially  a  children's  disease  and  rarely,  if  ever, 
attacks  the  scalp  after  puberty. 

Tinea  circinata,  or  ringworm  of  the  body,  usually  begins  as  a  slightly 
raised  circular  spot  presenting  a  red  furfuraceous  surface  upon  the  face, 
neck,  dorsum  of  hands  and  other  nonhairy  portions  of  the  body.  From 
one-eighth  of  an  inch  it  may  slowly  extend  its  periphery  to  one  or  two 
inches.  During  this  process  the  central  portion  resumes  the  appearance 
of  normal  skin  while  the  periphery  presents  a  ring  of  reddened  papules 
and  vesicles  undergoing  fine,  scaly  desquamation.  The  peripheries  of 
two  or  more  rings  may  approach  and  intersect  each  other  so  that  the 
interrupted  margins  form  serpentine  curves  like  a  figure  eight,  tre- 
foil, etc. 

Usually  after  a  few  weeks,  portions  of  the  raised  margin  subside  and 
gradually  the  affected  skin  regains  its  normal  condition,  while  the  devel- 
opment of  new  lesions  proceeds  in  other  localities.  A  chronic  form  is 
occasionally  encountered  in  which  the  lesions,  after  nearly  complete  dis- 
appearance, tend  to  recur  in  the  winter,  the  process  being  repeated  with 
change  of  season  for  a  number  of  years. 

In  the  rare  affection  of  the  nails,  tinea  unguium,  the  fungus  inserts 
itself  between  the  horny  layers  and  penetrates  the  nail  bed,  so  that 
growth  is  irregularly  arrested  with  resulting  distortion  and  deformity. 
Areas  of  crumbling  hypertrophy  alternate  with  healthy  nail  tissue. 
This  form  may  be  primary,  but  is  usually  secondary  to  lesions  elsewhere 
on  the  body. 

Ringworm  of  the  scalp  involves  not  only  the  epidermis,  but  also  the 
hair  follicles,  the  sheath,  and  the  capillary  cylinders  themselves.  The 
involved  areas,  like  the  disease  in  non-hairy  portions,  are  circular  and 
increase  gradually  by  extension  at  the  periphery,  but  show  different 
features  because  of  the  penetration  of  the  fungus  through  the  under- 
lying hair  follicles  to  the  deeper  layer  of  the  skin. 

Attention  is  first  called  to  this  disease  by  a  circumscribed  bald  spot 
which  upon  close  examination  shows  an  elevation  covered  with  fine, 
whitish,  powdery  scales.  These,  when  removed,  leave  the  surface  of  the 
scalp  slightly  red  or  bluish-gray  in  color,  according  to  the  complexion 
of  the  patient.  The  surface  bristles  with  irregular  stubs  of  broken-off 
hairs,  while  the  hairs  around  the  periphery  are  dry  and  lustreless.  The 
bald  patch  gradually  extends  in  all  directions  and  others  may  appear  in 
close  proximity  which,  coalescing,  produce  serpentine  tracts. 

In  both  this  form  and  tinea  corporis  there  may  be  more  or  less 
itching,  occasionally  scratching,  and  the  development  of  a  secondary 
eczema. 

The  disease  is  very  obstinate  to  treatment,  tends  to  ehronieity,  but 


616  DISEASES    OF    THE    SKIN 

rarely  extends  beyond  puberty.  "When  cured,  the  hairs  resume  their 
normal  growth,  although  occasionally  a  bald  spot  is  left. 

The  diagnosis,  aside  from  the  characteristics  above  mentioned,  is 
made  by  the  microscopic  demonstration  of  the  fungus  upon  the  hair 
root  plucked  from  the  affected  area. 

Children  suffering  from  tinea  should  be  kept  from  contact  with 
others.  Health-  and  school-boards  should  forbid  their  attendance  at 
schools  and  social  gatherings.  A  close-fitting  cap  should  be  worn  con- 
stantly to  prevent  dissemination  of  the  infection.  A  large  number  of 
parasiticides  have  been  employed  in  the  treatment  of  this  disease.  Their 
efficacy  depends  more  upon  the  method  of  employment  than  upon  the 
character  of  the  medicament.  Green  soap  alone  will  destroy  the  fungus, 
and  as  the  scales  must  be  removed  to  secure  access  to  the  follicles,  vigor- 
ous shampooing  with  sapo  viridis  should  precede  all  other  treatment. 
The  hair  immediately  surrounding  should  be  closely  cut.  After  drying 
from  the  shampoo,  one  of  the  following  medicaments  should  be  thor- 
oughly rubbed  into  the  affected  area :  an  ointment  of  the  oleate  of 
mercury  (five  to  ten  per  cent.)  ;  equal  parts  of  sulphur  ointment  and 
lard;  boroglyceride  (fifty  per  cent.)  ;  bichloride  of  mercury  (1  :500)r 
or  tincture  of  iodine.  With  the  exception  of  the  last-named,  these  appli- 
cations should  be  repeated  two  or  three  times  a  day,  as  the  spores  mature 
in  from  six  to  eight  hours.  Trichophytosis  capitis  is  the  most  refractory 
of  the  parasitic  skin  diseases,  and  occasionally  yields  only  after  several 
months  of  conscientious  treatment. 

A  few  applications  of  any  of  the  above-mentioned  agents  is  usually 
sufficient  to  effect  a  cure  in  tinea  circinata.  The  rare  affection  of  the 
nails  is  extremely  obstinate.  The  treatment  requires  removal  of  as  much 
of  the  horny  layers  as  possible  with  the  knife,  after  softening  with 
potash  solution.  This  is  followed  by  the  application  of  the  ointment  of 
oleate  of  mercury  (ten  to  twenty  per  cent.)  or  bichloride  of  mercury 
solution  (1  :  500). 

FAVUS — TINEA   FAVOSA;    CRUSTED   RINGWORM:    HONEYCOMBED   RESTGWORM. 

Favus  is  a  parasitic  disease  caused  by  the  fungus  achorion  Schon- 
leinii.  Like  trichophytosis,  this  disease  is  highly  contagious  and  may  be 
contracted  from  infected  persons  or  domestic  animals,  either  by  personal 
contact  or  by  dissemination  through  the  air.  "While  no  age  or  station 
is  exempt,  it  is  more  frequent  in  the  neglected  children  of  the  poor,  and 
is  quite  common  among  the  immigrants  from  eastern  and  southern 
Europe.  Its  favorite  location  is  upon  the  scalp,  but  it  is  occasionally 
found  upon  other  parts  of  the  body.  As  in  ringworm,  the  hair  fol- 
licles and  even  the  hairs  themselves  are  invaded  by  the  fungus,  caus- 
ing loss  of  lustre  and  final  atrophy  of  the  hair  bulb  with  permanent 
alopecia. 

Its  appearance  upon  the  scalp  is  in  circumscribed  yellowish  crusts 
showing  cup-like  depressions  (scutula).  These  areas  extend  and  the 
scutula  thicken  until,  in  neglected  cases,  the  entire  scalp  is  covered  with 


SCABIES  617 

massive  yellowish  crusts  which  present  the  characteristic  cup-like  depres- 
sions and  emit  a  peculiar  musty  odor.  The  crusts,  when  removed,  Leave 
a  depressed,  slightly  reddened,  or  pale  and  atrophied  surface  devoid  <>1" 
hair. 

Unlike  trichophytosis  there  is  no  tendency  to  spontaneous  recovery, 
neglected  cases  continuing  throughout  Life. 

Poorly-fed  children  show  a  predisposition  both  to  the  developmenl 
of  the  disease  and  its  persistency  under  treatment.  The  disease  may  be 
complicated  by  eczema  capitis,  rendering  microscopic  examination  of 
the  plucked  hairs  necessary  for  a  diagnosis. 

Treatment. — The  destruction  of  the  fungus  necessitates  the  removal 
of  the  crusts  and  the  plucking  of  the  hairs  from  the  follicles.  The  first 
may  be  accomplished  by  the  application  of  warm  oil  for  a  few  days, 
after  which  they  may  be  removed  by  a  blunt  curette  or  spatula.  The 
tedious  process  of  epilation  must  be  conscientiously  performed,  although 
several  sittings  may  be  necessary.  The  process  should  include  the 
entire  affected  area  and  a  liberal  margin,  as  the  diseased  follicles  extend 
beyond  the  visible  boundary.  Vigorous  shampooing  with  green  soap 
and  a  brush  may  be  practised  daily.  The  application  of  parasiticides  is 
similar  to  that  recommended  in  tinea  capitis. 

SCABIES — ITCH. 

This  disease  in  infants  differs  from  that  seen  in  the  adult  in  so  far 
as  the  greater  delicacy  of  the  skin  encourages  its  wider  distribution,  and 
the  uncontrollable  scratching  adds  traumatic  lesions  to  those  made  by 
the  itch  mite. 

The  female  acarus,  burrowing  in  the  tenderest  portion  of  the  skin  to 
deposit  her  eggs,  causes  minute  papular  vesicles  and  pustules,  first  upon 
the  wrists,  between  the  fingers,  and  in  the  flexures  of  the  body  and  limbs. 
The  face  is  never  affected  except  in  young  infants.  In  neglected  cases 
the  skin  over  all  parts  of  the  body,  even  the  soles  and  palms,  may  be  the 
seat  of  lesions.  The  cuniculi  may  be  obscured  by  the  profuse  eruption 
of  vesicles,  or  pustules  may  form  beneath  the  denser  portions  of  the 
skin,  and  scratching  change  the  character  of  the  primary  lesions. 

The  diagnosis  is  usually  not  difficult.  Itching  lesions  on  the  wrists 
and  hands  of  a  child  are  suggestive  of  scabies,  and  inquiry  will  usually 
reveal  the  disease  in  other  members  of  the  household. 

Linear  excoriations  upon  portions  of  the  body  accessible  to  the  child 's 
hands  are  usually  in  evidence,  while  examination  with  a  lens  will  show 
the  burrows  like  dark  lines  from  one  to  six  millimetres  in  length  beneath 
the  epithelium. 

It  should  be  remembered  that  scabies  may  complicate  eczema,  im- 
petigo, urticaria,  and  other  skin  affections  of  totally  different  nature, 
and  that  the  primary  lesions  may  become  infected  with  different  varieties 
of  pus  germs. 

Treatment. — The  cure  of  scabies,  though  seemingly  simple,  requires 
attention  to  details,  which  may  include  the  treatment  of  other  members 


618  DISEASES    OF    THE    SKIN 

of  the  household.  Bedding  and  clothing  used  by  the  child  must  be  dis- 
infected by  fumigation  or  heat  (steaming,  baking,  or  boiling). 

After  a  thorough  scrubbing  with  green  soap  and  hot  water,  a  para- 
siticide should  be  applied  to  the  affected  skin  and  the  child  put  into  a 
clean  bed. 

For  older  children  nothing  is  better  than  the  official  sulphur  oint- 
ment. For  younger  children  this  should  be  modified  by  adding  an  equal 
quantity  of  Peruvian  balsam  and  six  parts  of  vaseline,  while  the  delicate 
skin  of  the  young  infant  may  be  treated  with  balsam  of  Peru  one  part, 
to  two  of  glycerin.  These  applications  should  be  repeated  for  three  or 
four  successive  nights,  after  which  a  thorough  cleansing  bath  and  clean 
clothes  will  complete  the  cure. 

PEDICULOSIS. 

The  pediculus  capitis  is  not  an  infrequent  guest  on  the  heads  of 
school  children  and  occasionally  of  younger  children  in  neglected  fam- 
ilies. Sores  on  the  posterior  portion  of  the  scalp  or  enlargement  of  the 
postcervical  lymph  nodes  should  lead  to  a  careful  examination  for  lice. 
Nits  (ova)  clinging  to  the  hairs  are  sometimes  the  only  evidence  of  the 
parasite.  The  pediculus  pubis,  which  occasionally  infests  the  eyebrows' 
and  the  finer  hair  of  the  nucha,  is  so  small  as  to  escape  detection  without 
the  aid  of  a  glass.  This  louse  may  be  seen  as  a  minute  dark  red  speck 
lying  quietly  close  to  the  skin,  from  which  it  may  be  lifted  with  the 
point  of  a  needle,  whereupon  it  shows  remarkable  activity. 

The  itching  clue  to  louse  bites  may  induce  scratching,  which  causes 
excoriations  of  the  scalp.  These,  becoming  infected,  may  occasion  ulcers 
and  crusts,  or  this  parasite  may  add  to  the  torture  of  eczema  capitis. 
Lousy  heads  are  so  common  among  applicants  for  admission  to  hospitals 
and  dispensaries  that  a  routine  treatment  is  adopted.  It  is  rarely 
necessary  to  cut  the  hair,  but  it  should  be  thoroughly  shampooed  with 
soap  containing  sulphur,  tar,  or  resinol.  After  rinsing  and  drying, 
unguentum  hydrargyri  may  be  lightly  applied  to  the  roots  of  the  hair 
with  the  tip  of  the  finger.  The  treatment  may  be  repeated  twice,  with 
intervals  of  two  or  three  days.  Equally  effective  is  washing  the  head 
with  vinegar  or  spirits  of  camphor  after  a  thorough  shampoo  with  green 
soap. 

The  pubic  louse  retires  after  one  or  two  applications  of  a  one  per  cent, 
solution  of  carbolic  acid. 

FURUNCULOSIS. 

Boils  may  occur  in  children  of  all  ages  as  well  as  in  adults.  A 
peculiar  form  is  seen  in  infancy  in  which  the  lesions  are  multiple. 
These  may  occur  on  any  part  of  the  body,  but  are  most  frequently  sit- 
uated on  the  face,  neck,  and  scalp.  They  may  vary  in  size  from  a  grain 
of  wheat  to  a  walnut ;  are  dull  red  or  purple,  soft  and  indolent,  occurring 
in  crops;  are  less  painful  than  the  sporadic  furuncle,  rarely  contain  a 
core,  and  when  incised  discharge  a  dark,  bloody  purulent  matter. 
Furunculosis  is  most  frequently  seen  in  poorly  nourished  infants  and 


PSORIASIS  619 

those  recovering  from  a  prolonged  illness.  The  lesions  are  often  indolent 
and  may  occur  as  a  sequel  to  other  acute  disorders  oi*  the  skin.  They 
may  result  in  abscesses  and  occasionally  in  gangrenous  processes. 

The  treatment  should  be  hygienic,  including  properly  balanced  food, 
with  the  administration  of  cod-liver  oil  and  compound  syrup  of  hypo- 
phosphites.  The  skin  should  be  kept  clean  and  frequently  moistened 
with  solutions  of  boric  acid.  Incipient  boils  may  occasionally  be  aborted 
by  tincture  of  iodine,  strong  spirits  of  camphor,  or  one  per  cent,  solu- 
tion of  carbolic  acid.  As  soon  as  pointing  occurs  the  contents  should 
be  evacuated  by  an  incision,  the  cavity  cleansed  with  bichloride  of  mer- 
cury (1  :2000),  and  a  firm  compress,  wet  with  boric  acid,  applied  to 
prevent  refilling.  The  use  of  calcium  sulphate  and  alkalies  in  furuncu- 
losis  has  long  been  advocated. 

PSORIASIS. 

Psoriasis  in  childhood  presents  some  peculiarities,  among  which  are 
its  milder  character,  its  usually  discrete  form,  and  greater  tractability 
to  treatment.  It  is  often  hereditary,  being  present  in  two  or  more 
generations.  Although  rare  before  the  sixth,  it  has  been  seen  during  the 
first  year  of  life. 

Psoriasis  should  be  differentiated  from  eczema  by  the  greater  pro- 
fusion of  scales,  absence  of  infiltration  of  the  skin,  less  pruritus,  and  its 
symmetrical  location  upon  the  flexor  surfaces.  Seborrhoea  differs  from 
psoriasis  of  the  scalp  by  the  presence  of  crusts  that  are  greasy  and 
friable  to  touch.  Removal  of  the  crusts  of  seborrhoea  leaves  a  pallid 
surface  rather  than  the  easily  bleeding  one  of  psoriasis. 

In  syphilis  some  lesions  may  be  found  upon  the  palms  and  soles ; 
psoriasis  never  attacks  the  hands  and  feet.  Syphilitic  scales  are  of  a 
dirty  color  and  do  not  extend  to  the  margin  of  the  inflamed  patch, 
while  psoriasis  shows  abundant  pearly  scales  that  crowd  over  upon  the 
healthy  skin.  The  coppery  hue  of  syphilitic  lesions,  the  presence  of 
mucous  patches,  and  the  ready  yielding  to  specific  treatment,  will  help 
to  exclude  psoriasis  in  doubtful  cases. 

Ichthyosis  is  usually  a  disease  of  early  infancy,  is  unattended  by 
evidences  of  inflammation,  and  shows  a  rough,  dry  skin ;  while  psoriasis 
is  rarely  seen  before  the  sixth  year,  and  presents  healthy  skin  between 
its  patches  of  silvery  scales. 

Treatment. — Arsenic  has  proved  the  most  valuable  internal  remedy 
and  should  be  continued  for  some  months.  Thyroid  extract  has  been 
administered  with  apparent  success  in  some  cases.  Locally,  ichthyol  oint- 
ment (five  to  ten  per  cent.)  may  be  used  after  removal  of  the  scales  by 
vigorous  shampooing  with  green  soap.  Chrysarobin  in  vaseline  or  col- 
lodion (two  to  five  per  cent.)  every  third  or  fourth  day,  is  probably  the 
most  efficient  remedy.  In  the  employment  of  this  drug  the  danger  of  irri- 
tation of  the  eyes  and  adjoining  normal  skin  must  be  kept  in  mind.  The 
daily  use  of  hot  water  and  soap  is  a  necessary  adjunct  to  any  treatment 
of  psoriasis.     The  obstinacy  of  the  disease  and  its  well-known  tendency 


620  DISEASES    OF    THE    SKIN 

to  remissions  and  recurrences  are  prominent  among  the  surprising  and 
perplexing  features  of  dermal  therapy. 

ICHTHYOSIS. 

Ichthyosis  is  generally  regarded  as  a  congenital  deformity  rather 
than  a  disease.  The  paucity  of  normal  secretions  leaves  the  skin  dry, 
with  apparent  hypertrophy  of  the  horny  layer.  It  is  usually  congenital 
and  probably  always  hereditary.  Even  cases  which  develop  in  later 
childhood  show  a  family  tendency.  Occasionally  a  generation  is  exempt 
from  the  disease,  which  reappears  in  their  progeny.  Further  than  this 
family  tendency,  the  cause  is  unknown. 

Different  degrees  of  this  dermal  defect  are  described  which  has  re- 
sulted in  no  little  confusion  as  to  the  pathology  and  prognosis  of  ich- 
thyosis. Ignoring  the  refinements  of  clinical  differentiation,  it  is.  safe 
to  assume  that  ichthyosis  developing  at  any  period  of  childhood  is 
congenital,  and  that  any  persistent,  dry,  parchment-like,  noninflamma- 
tory condition  of  the  skin  which  spares  the  flexor  surfaces,  is  ichthyosis. 
Milder  degrees  may  show  only  a  roughening  of  the  skin  (xeroderma), 
principally  on  the  arms  and  thighs.  In  severe  types  the  epidermal  layer 
of  any  portion  of  the  body  is  cracked  into  irregular,  polygonal  shapes, 
or  scutula,  whose  loosened,  upturned  edges  suggest  fish-scales, — hence 
the  name.  This  scaly  skin  presents  a  dirty-gray  and  sometimes  pig- 
mented appearance,  with  intervening  fissures  of  red  skin  or  raw  surfaces 
denuded  of  epithelium. 

In  young  infants  the  general  appearance  suggests  that  the  foetus 
in  utero  was  hidebound  and  its  subsequent  growth  burst  the  inelastic 
epidermis  by  underlying  muscle  contractions.  When  occurring  in  the 
newly  born,  other  congenital  defects — as  malformations  of  the  ears,  nose, 
mouth,  palpebral  fissures  and  fingers — are  often  associated.  In  severe 
cases  the  infants  rarely  survive  more  than  a  few  hours  or  days.  The 
disease  as  it  occurs  in  the  second  or  third  year  of  life  (ichthyosis  vul- 
garis) shows  variations  in  severity  which  correspond  with  the  general 
health  and  changes  of  season  (always  worse  in  the  winter),  also  with 
complicating  dermal  lesions, — as  eczema  or  dermatitis. 

The  course  is  essentially  chronic  and  incurable,  though  the  condition 
may  be  ameliorated  by  treatment  and  attention  to  hygiene.  Ichthyosis 
has  been  known  to  disappear  after  an  attack  of  one  of  the  exanthemata,, 
to  reappear  at  a  later  period. 

The  diagnosis  of  a  well-marked  case  of  ichthyosis  is  unmistakable. 
In  questionable  cases  the  fact  that  this  disease  spares  the  flexor  sur- 
faces and  presents  no  subjective  symptoms  may  be  of  differential 
value. 

Treatment. — In  young  infants  a  continuous  warm  bath  of  five  or  six 
days '  duration  has  proved  beneficial  in  some  hands.  In  general  the  treat- 
ment requires  warm  baths  and  thorough  scrubbing  with  green  soap  two  or 
three  times  a  week  to  loosen  the  epithelium.  This  should  be  followed 
by  the  application  of  glycerole  of  starch.     In  addition,  in  severe  cases, 


ICHTHYOSIS  621 

the  scaly  surfaces  may  be  anointed  with  a  small  quantity  of  pure 
glycerin,  the  hygroscopic  property  of  which  absorbs  moisture  from 
the  air  and  prevents  desiccation.  Daily  inunctions  with  cod-liver  oil, 
cacao-butter,  lanolin,  or  the  mixed  fats  may  be  used.  Stimulation  of 
the  sudoriparous  glands  by  Turkish  or  vapor  baths  is  highly  recom- 
mended, and  the  administration  of  jaborandi  has  been  advocated, 
although  in  infants  such  measures  should  be  applied  with  extreme 
caution.  From  the  fact  that  the  thyroid  gland  has  been  found  defective 
in  some  ichthyotic  children,  thyroid  treatment  seems  rational  and  worthy 
of  trial.  The  internal  use  of  cod-liver  oil  and  arsenic  has  seemed  bene- 
ficial in  many  cases.  It  should  be  remembered  that  ichthyosis  usually 
improves  in  the  summer  months  and  is  aggravated  by  cold,  from  which 
fact  residence  in  a  semi-tropical  climate  is  the  easiest  mode  of  treatment 
for  these  children. 

Moderate  degrees  of  ichthyosis,  while  not  dangerous  to  life,  may  so 
interfere  with  the  normal  function  of  the  skin  as  to  render  the  patient 
extremely  susceptible  to  metabolic  perversions  and  infectious  disorders, 
constituting  a  general  feebleness  of  resistance. 

SCLERODERMA — DERMATOSCLEROSIS  ;    CUTIS   TENSA    CHRONICA. 

While  usually  a  disease  of  adult  life,  scleroderma  is  occasionally  met 
with  in  children.  This  disease  should  not  be  confounded  with  sclerema 
neonatorum.  The  etiology  is  obscure,  although  it  has  been  known  to 
develop  after  prolonged  exposure  of  a  portion  of  the  body  to  cold. 

The  disease  develops  slowly,  the  lesions  appearing  somewhat  sym- 
metrically, in  which  there  are  local  swelling  and  induration,  with  either 
waxy  pallor  or  dirty-gray  mottled  redness.  The  affected  areas  have  a 
hard,  tallow-  or  corpse-like  feel,  but  seldom  pit  under  pressure.  Later, 
atrophy  occurs,  after  which  the  skin  is  tightly  drawn  (skin-bound),  and 
is  adherent  to  the  subjacent  muscles  or  bony  prominences. 

The  sclerosis  may  occur  in  strips  or  bands  which  constrict  the  under- 
lying tissues  and  may  limit  motion.  If  on  the  face  the  expression  is 
wooden  (sclerodermic  mask).  If  on  the  hands,  the  fingers  may  be  partly 
flexed,  rigid,  and  the  hands  atrophied  and  claw-like. 

Both  local  and  general  temperature  may  be  subnormal.  There  is 
connective-tissue  hypertrophy  and  lymph  stasis,  with  enlargement  of 
the  lymph  spaces. 

The  disease  is  rarely  fatal,  although  chronic  and  refractory  to 
treatment.  Spontaneous  improvement  and  even  recovery  occasionally 
occur. 

Treatment. — Internal  medication  is  of  little  avail.  Good  nutrition 
must  be  secured.  Local  treatment — as  oily  inunction  with  vigorous 
massage,  hot  baths,  and  salt  rubbings — gives  the  best  results  and  is 
sometimes  followed  by  marked  improvement,  especially  if  employed  prior 
to  extreme  atrophy.  When  the  hands  and  fingers  are  the  seat  of  the 
disease,  burying  them  for  an  hour  at  a  time  in  a  box  of  hot  sand 
improves  their  mobility.    Galvanism  also  stimulates  local  circulation. 


622  DISEASES    OF    THE    SKIX 

XERODERMA    PIGMENTOSUM MELANOSIS     LENTICULARIS     PROGRESSIVA;     KA- 
POSI 'S  DISEASE  ;    ANGIOMA  PIGMENTOSUM  ET  ATROPHICUM. 

Xeroderma  pigmentosum  is  a  rare  disease,  beginning  in  infancy  occa- 
sionally as  early  as  the  third  month.  The  cause  of  the  disease  is 
unknown,  but  it  presents  a  distinct  familial  type. 

It  usually  appears  first  on  the  face,  hands,  or  other  exposed  surfaces 
in  pigmented  spots  like  ordinary  freckles.  The  intervening  spaces  soon 
show  depressions  which  resemble  the  cicatrices  of  smallpox.  Small 
areas  of  hyperemia,  telangiectasis,  and  soft  warty  growths  develop  later 
until  all  portions  of  the  skin  not  protected  by  clothing  present  these 
multiform  lesions.  Later,  atrophy  and  ulceration  of  the  new  growths 
occur,  with  cicatricial  deformities  of  the  mouth,  nose,  and  eyes  (ectro- 
pion ).  Masses,  resembling  keloid  and  lupus-like  ulcers,  appear  on  differ- 
ent parts  of  the  surface  in  increasing  numbers  as  the  disease  progresses. 
The  blood  shows  no  constant  changes. 

The  course  of  xeroderma  pigmentosum  is  chronic,  and  may  extend  to 
twenty  years,  with  an  invariably  fatal  termination.  The  neoplasms  in 
a  large  proportion  of  the  cases  sooner  or  later  become  malignant. 

Xo  therapy  is  as  yet  known  to  be  beneficial.  As  this  disease  affects 
the  portions  of  the  body  exposed  to  light,  treatment  by  exclusion  of 
certain  rays  has  been  suggested.  In  a  few  cases  exposure  to  light  passed 
through  red  and  green  glass  has  been  tried  with  practically  negative 
results. 

VERRUCA — WARTS. 

vVarts.  although  occurring  at  any  age,  are  very  common  in  childhood 
and  may  be  congenital.  Many  varieties  are  described  in  terms  sug- 
gested by  difference  in  form, — sessile,  acuminate,  digitate,  filiform,  etc. 
They  consist  of  papillary  excrescences  which  arise  from  a  connective 
tissue  base,  are  supplied  with  a  vascular  loop,  and  are  covered  with  a 
more  or  less  hypertrophied  epidermis. 

The  greatest  interest  centres  around  the  etiology,  which  is  little 
understood,  although  there  is  a  revival  of  the  older  belief  in  their  con- 
tagious and  autoinfectious  character.  That  they  are  sometimes  of 
trophoneurotic  origin  is  suggested  by  their  sudden  development  and  as 
sudden  disappearance  under  sympathetic  influences. 

Warts  are  never  painful  unless  injured,  and  are  of  little  importance 
except  as  a  curiosity,  since  the  warts  of  childhood  rarely  persist  beyond 
that  period.  Their  unsightliness  and  occasional  inconvenience  stimulate 
efforts  at  removal.  This  may  be  accomplished  by  the  firm  application 
of  a  compress  saturated  with  salicylic  acid  solution,  or  by  painting  for 
three  or  four  successive  nights  with  salicylic  acid  and  flexible  collodion 
(1:10).  After  this  the  horny  hypertrophy  may  be  rasped  down. 
Filiform  and  pedunculated  warts  may  be  clipped  off  with  scissors  and 
the  base  touched  with  tincture  of  iodine  or  solid  nitrate  of  silver.  "Warty 
children  often  show  other  evidences  of  malnutrition,  in  which  case  the 
hygiene  should  receive  attention.    Iron  should  be  exhibited  for  anaemia, 


(EDEMATA  623 

while  arsenic  in  moderate  doses  seems  to  have  a  specific  effect  in  Borne 
cases.  It  is  claimed  that  the  persistent  administration  of  magnesium  sul- 
phate in  small  doses  will  arrest  the  development  of  verruca. 

(EDEMATA. 

Many  varieties  of  oedema  occur  during  infancy  and  childhood.  Vari- 
ous causes  operate  to  produce  this  condition,  such  as  obstruction  to  the 
lymphatic  or  venous  circulation,  also  dilatation  of  the  capillaries,  or 
atony  of  the  arterioles.  Thus  the  oedema  of  cardiac  insufficiency,  with 
or  without  valvular  lesions ;  renal  insufficiency,  with  or  without  albu- 
minuria and  casts;  enlargement  of  liver,  spleen,  mediastinal,  cervical, 
axillary,  inguinal,  and  mesenteric  lymph-nodes,  are  familiar  pictures. 
So  also  is  the  anasarca  of  the  extremities  common  to  extreme  marasmus 
and  anaemia.  (Edema  may  be  due  to  toxins,  whether  locally  applied,  as 
the  sting  of  insects,  or  circulating  in  the  blood,  as  in  uraemia. 

It  is  safe  to  assume  that  all  oedemata  are  secondary.  Since  in  some 
instances  the  primary  cause  is  indeterminate  such  terms  as  idiopathic, 
neurotic,  essential,  and  angioneurotic  have  been  employed.  Some  chil- 
dren develop  swelling  of  the  face,  hands,  feet,  or  other  areas,  in  a  few 
hours,  which  may  as  quickly  subside,  and  for  which  no  known  disturb- 
ance of  heart,  kidneys,  or  blood  may  be  held  responsible.  This  tendency 
in  some  instances  amounts  to  a  diathesis  and  appears  to  be  hereditary. 
Occasionally  it  occurs  from  reflex  irritation  of  the  genitals,  mouth,  or 
gastro-enteric  tract,  and  at  times  seems  closely  allied  to  urticaria.  The 
term  gigantic  urticaria  is  still  employed  by  some  writers  for  angioneu- 
rotic oedema. 

It  is  rarely  dangerous,  save  when  the  epiglottis,  larynx,  or  lungs  are 
involved,  and  usually  subsides  as  quickly  as  it  appears,  but  shows  a  ten- 
dency to  recur.  Unlike  the  wheals  of  urticaria,  areas  of  neurotic  oedema 
do  not  itch,  and  no  discomfort  usually  attends  their  appearance,  except 
a  feeling  of  tension  and  stiffness  due  to  the  swelling. 

The  treatment  should  be  addressed  to  any  known  local  irritation. 
Eliminations  should  be  promoted  by  saline  laxatives  and  alkaline  diu- 
retics, and  nutrition  maintained  by  bland,  easily  digested  food. 


CHAPTER   XVII 
GENERAL    DISEASES 

DIABETES   MELLITUS 

Most  authorities  agree  in  the  statement  that  diabetes  mellitus  is  rarely 
found  in  the  extremes  of  life,  but  give  no  comparative  figures. 

The  fact  that  analysis  of  urine  is  now  recognized  by  the  majority 
of  the  profession  as  an  essential  procedure  in  the  examination  of  adults 
may  help  to  explain  the  recent  increase  in  the  total  number  of  diabetic 
patients  reported.  If  this  be  true  it  may  not  be  unreasonable  to  urge 
that  the  well-known  neglect  to  examine  the  urine  of  little  patients  may 
partially  account  for  the  seeming  rarity  of  this  disorder  in  young 
children. 

Since  vital  statistics  furnish  the  only  information  on  this  subject, 
the  following  deductions  from  Stern's  comments  on  the  official  records 
of  New  York  City,  also  from  figures  obtained  through  the  courtesy  of 
Assistant  Commissioner  Reilly,  of  the  Chicago  Health  Department,  are 
presented : 

NEW   YORK   FOB   TEN   YEARS. 

Number  of  deaths 
Age.  from  diabetes.  Percentage. 

All  ages    1867  100.00 

Under  10  years   24  1.24 

Under  1  year 4  0.21 

CHICAGO  FOE  FOUR  YEARS. 

All  ages    418  100.00 

Under  10  years   15  3.5 

Under  1  year    3  0.7 

In  Chicago,  during  this  period,  the  deaths  from  diabetes  are  0.44 
per  cent,  of  deaths  from  all  causes.  Deaths  under  ten  years  of  age  from 
diabetes  were  0.04  per  cent,  of  deaths  from  all  causes. 

That  heredity  plays  a  role  in  the  predisposition  to  diabetes  mellitus 
there  seems  to  be  little  doubt,  since  its  history,  or  that  of  allied  con- 
ditions— such  as  gout,  tuberculosis,  and  other  diathetic  disorders — in  the 
immediate  ancestry,  occurs  too  frequently  to  be  passed  by  as  a  mere 
coincidence.  Different  observers  have  noted  the  presence  of  heredity  in 
from  ten  to  thirty  per  cent,  of  their  cases.  It  is  claimed  that  dia- 
betes may  be  congenital.  It  has  been  found  not  only  in  the  infant  of 
three  months,  but  in  the  saccharin-hydramnion  surrounding  the  dead 
foetus  of  a  diabetic  mother. 

Diabetes  associated  with  congenital  syphilis  has  yielded  to  antisyphi- 
litic  treatment,  and  glycosuria  in  cretins  has  cleared  up  under  thyroid 
treatment. 
624 


DIABETES    MELLITUS  625 

Some  are  inclined  to  attribute  to  the  infectious  diseases  of  childhood 
a  causal  relation  to  diabetes  mellitus,  although  ii  is  not  improbable  that 
the  closer  attention  induced  by  the  acute  disorder  has  occasionally  Led 
to  the  discovery  of  a  pre-existing  glycosuria.  It  is  well  known  that 
attacks  of  some  of  the  acute  infect  ions  are  frequently  accompanied  hy  a 
disappearance  of  sugar  from  the  urine  of  diabetics.  The  same  phenome- 
non has  been  observed  during  an  attack  of  jaundice  in  a  child. 

In  some  instances  diabetes  has  been  known  to  follow  traumatisms — 
especially  blows  on  the  head — psychic  shocks,  fatigue,  or  exposure  to 
debilitating  influences.  Any  one  of  these  exciting  causes  may  act  to  pro- 
duce transient  glycosuria,  and  the  patient,  recovering  from  the  disturb- 
ance, may  subsequently,  even  after  a  period  of  years,  develop  a  serious 
diabetes.  • 

It  has  been  found  by  injections  of  sterilized  sugar  solution  into  the 
circulation,  that  the  glycogen  storage  capacity  of  the  tissues  is  relatively 
high  in  infants.  From  this  it  might  be  inferred  that  transient  glyco- 
suria, at  least  as  far  as  it  is  dependent  on  overingestion  of  carbohydrates, 
would  be  of  less  frequent  occurrence  in  infants  than  in  adults. 

Since  the  obese  type  of  diabetes  is  practically  unknown  in  early  child- 
hood, an  advanced  case  presents  a  picture  of  extreme  emaciation,  mus- 
cular weakness,  dry  skin  and  hair,  brittle  nails,  extreme  irritability,  and 
sensitiveness  to  cold.  The  special  symptoms — polyphagia,  polydipsia, 
and  polyuria — are  always  present. 

Furunculosis  and  other  skin  lesions  appear  less  frequently  in  child- 
hood than  in  adult  life.  The  rarity  of  a  complicating  albuminuria  has 
been  attributed  to  the  integrity  of  the  kidneys  and  the  great  supple- 
ness of  the  vascular  system  in  early  life. 

Any  of  the  nervous  and  ocular  symptoms  frequently  associated  with 
adult  diabetes — such  as  symmetrical  neuralgia,  neuritis,  motor,  sensory, 
trophic,  or  psychic  disturbances,  also  amblyopia,  cataract,  iritis,  or  reti- 
nitis— may  be  present  in  children. 

Children  who  exhibit  symptoms  of  trophic  disturbances,  or  obscure 
neuroses,  and  a  family  history  of  diabetes,  should  be  given  full  diet 
of  mixed  carbohydrates  and  its  effect  watched  for  the  production  of 
glycosuria. 

The  disease  in  childhood  is  essentially  acute.  Cases  that  survive  more 
than  a  few  months  are  rare. 

Treatment. — So  long  as  the  etiology,  and  even  the  pathology,  is  in- 
volved in  the  obscurity  which  obtains  at  present,  no  routine  treatment 
applicable  to  even  the  majority  of  cases  may  be  formulated.  Of  the  many 
drugs  that  have  found  advocates — such  as  bromide's,  antipyrin,  sodium 
salicylate,  etc. — few,  if  any,  have  been  approved  by  more  than  a  very 
limited  number  of  clinicians.  With  perhaps  the  exception  of  opium. 
which  seems  to  retard  the  progress  of  the  disease,  and  alkalies  to  coun- 
teract the  acidosis  and  impending  coma,  the  benefits  of  drug  therapy  are 
admittedly  restricted  to  rare,  exceptional  eases.  Againsl  the  high  rate 
of  mortality  from  this  disorder  in  childhood,  the  limited  utility  of  opium 

40 


626  GENERAL    DISEASES 

affords  but  little  encouragement.  The  prolongation  of  a  life,  with  the 
establishment  of  the  opium  habit  at  its  threshold,  is  not  sufficient  com- 
pensation. 

The  severe  form  is  the  one  most  frequently  seen  in  early  childhood, 
and  the  rapid  course  of  the  disease  is  rarely  influenced  by  therapy.  The 
death  certificate  follows  hard  upon  the  diagnosis.  These  facts  enhance 
the  value  of  prophylaxis. 

It  is  now  believed  that  diabetes,  if  not  an  hereditary  disease,  at  least 
develops  along  the  lines  of  a  somewhat  positive  diathesis.  To  the  extent 
that  the  function  of  the  family  physician  is  supervisory  over  his  patients 
may  he  hope  to  avert  such  disorders  by  controlling  their  development 
through  attention  to  hygiene.  The  young,  whose  immediate  or  remote 
ancestry  shows  diabetes,  gout,  tuberculosis,  neuroses,  or  syphilis,  should 
be  sedulously  guarded.  Dietary  errors — such  as  the  ingestion  of  food 
beyond  the  child's  capacity  for  absorption  and  assimilation,  or  the  pre- 
ponderance of  saccharine  substances,  as  sweetmeats,  confections,  and 
pastries — must  be  carefully  avoided. 

That  the  elimination  in  these  little  patients  is  of  the  utmost  impor- 
tance receives  additional  significance  from  many  observations  which 
emphasize  autoinfection  and  reinfection  as  etiologic  factors.  It  is  of 
interest  in  this  connection  to  mention  that  injection  of  fasces  as  well 
as  the  urine  of  diabetic  patients  in  lower  animals  will  reproduce  glyco- 
suria. A  thorough  care  of  the  digestive  tract,  including  the  teeth,  is  all- 
important.  So,  too.  is  the  care  of  the  skin  and  respiratory  organs  that 
elimination  by  the  former  and  oxygenation  through  the  latter  may  attain 
the  highest  possible  perfection.  Adenoids  should  receive  attention,  as 
well  as  other  evidences  of  lymphadenitis. 

Especially  should  these  children  be  protected  from  mental  strain, 
shocks,  frights,  trauma,  and  exposure  to  inclement  weather,  since  cases 
are  reported  in  which  the  development  of  glycosuria  was  preceded  by 
such  disturbances. 

In  a  child  diabetes  may  be  anticipated  by  the  appearance  of  pre- 
glycosuric  signs,  such  as  incontinence  of  urine,  muscular  debility,  irrita- 
bility with  progressive  emaciation  (in  spite  of  voracious  appetite),  even 
though  a  single  test  of  the  urine  fail  to  reveal  sugar.  The  importance  of 
an  early  diagnosis  is  evident,  for  it  is  admitted  that  success  in  treatment 
bears  an  inverse  ratio  to  the  previous  continuance  of  the  disease. 

At  the  present  time  the  regulation  of  diet  seems  to  be  the  most  im- 
portant therapeutic  measure,  and  by  far  the  greater  number  of  impor- 
tant improvements  have  been  attributed  to  this  mode  of  treatment. 

Fat  is  absolutely  essential  to  the  diet,  and  may  be  taken  up  to  the 
limit  of  gastric  toleration. 

Recent  investigations  have  shown  that  a  certain  amount  of  carbo- 
hydrates is  necessary  for  the  reduction  of  acetonuria  and  that  a  single 
member  of  this  group  is  better  borne  than  mixed  carbohydrates.  It  is 
also  claimed  that  a  single  form  of  albumin  is  more  tolerable  than  a 
variety  of  proteid  foods,  and,  further,  that  an  excessive  meat  diet  in- 


DIABETES    INSIPIDUS  627 

creases  1 1 1< ■  acidosis.  Hence  Van  Noorden  has  recommended  a  mixture 
consisting  of  oatmeal  gruel,  egg  albumen,  and  butter  freed  of  fatty  acids 
by  washing  in  cold  water.  Sucb  a  mixture  should  not  be  made  the  exclu- 
sive diet  for  more  than  three  or  four  days,  on  account  of  distrust  at  the 
monotony. 

Alkalies,  as  bicarbonate  and  citrate  of  sodium,  to  combat  the  acidosis, 
should  be  administered  in  quantities  sufficient  to  render  the  urine  neutral. 

The  utmost  care  of  the  diet  and  hygiene  is  even  more  important  in 
children  than  in  adults,  since  a  higher  ratio  of  metabolism  is  essential 
to  growth  in  addition  to  repair.  But  the  child  will  not  bear  radical 
dietary  changes  well.  Hence,  although  so  important,  the  reduction  of 
carbohydrates  should  be  gradual.  The  same  may  be  said  of  the  augmen- 
tation of  fats.  Finally,  too  much  stress  cannot  be  laid  upon  the  impor- 
tance of  protecting  the  child  form  a  sudden  lowering  of  the  temperature. 

DIABETES   INSIPIDUS. 

Diabetes  insipidus  is  still  classed  as  a  disease.  As  at  present  under- 
stood, the  term  represents  a  persistent  polyuria  of  unknown  etiology. 
As  such  it  is  an  extremely  rare  disorder.  No  age  is  exempt,  and  infancy 
and  childhood  furnish  their  full  proportion  of  cases.  There  is  reason 
to  believe  there  is  a  hereditary  element,  as  cases  have  been  traced  through 
four  generations,  and  sometimes  several  members  of  the  same  generation 
have  been  affected.  The  quantity  of  urine  passed  may  be  enormous, — 
in  some  instances  reaching  ten  times  the  normal  quantity.  It  is  of  very 
low  specific  gravity,  from  1001  to  1006,  usually  of  acid  reaction,  and. 
with  the  possible  exception  of  inosite,  contains  no  abnormal  constituent. 
The  total  solids  excreted,  as  a  rule,  are  slightly  above  the  average  for 
the  weight  of  the  patient  and  amount  of  food  ingested.  No  constant 
anatomic  lesion  has  been  found,  excepting  some  enlargement  of  the 
kidneys,  dilatation  of  ureters,  and  hypertrophy  of  the  bladder. 

The  onset  is  sometimes  sudden,  following  shock,  fright,  traumatism, 
or  the  drinking  of  unusually  large  quantities  of  fluid.  More  frequently 
the  development  is  gradual,  attention  being  first  attracted  by  the  fre- 
quency of  micturition  at  night.  Strangely  enough,  among  older  children 
nocturnal  incontinence  is  not  of  frequent  occurrence,  the  bladder  show- 
ing a  remarkable  degree  of  tolerance.  Polydipsia  is  always  present,  and 
while  a  fairly  constant  relation  exists  between  the  amount  of  urine  and 
the  quantity  of  fluid  ingested,  the  former  is  always  in  excesss  of  the  lat- 
ter. The  general  health  may  not  appear  to  suffer  for  many  weeks,  yet 
there  is  usually  considerable  irritability.  Later  there  is  loss  of  flesh, 
with  muscular  atony,  disinclination  to  exertion,  and  tendency  to  somno- 
lency. The  appetite  is  imperative,  and  the  digestion  is  disturbed  only 
as  the  patient  yields  to  the  bulimia.  Constipation  is  the  rule,  due  largely 
to  the  diversion  of  fluids  to  the  urinary  tract.  The  skin  is  dry.  perspi- 
ration not  being  perceptible.  The  temperature  is  rarely  elevated;  usu- 
ally subnormal. 

The  quantity  of  urine  in  healthy  subjects  is  normally  increased  by 


628  GENERAL    DISEASES 

the  quantity  of  fluids  ingested.  There  are  many  known  causes  of  poly- 
uria,— such  as  hysteria,  fright,  any  nerve  shock  or  mental  emotion,  expo- 
sure to  cold,  reflex  irritation  (as  from  presence  of  worms  in  the  alimen- 
tary tract) ,  and  absorption  of  effusions.  It  is  also  seen  in  the  early  days 
of  convalescence  from  acute  infections,  and  it  is  well  known  that  irri- 
tation of  the  floor  of  the  fourth  ventricle  produces  polyuria.  The  con- 
tracted kidney  of  interstitial  nephritis  must  be  excluded  by  a  careful 
examination  of  the  urine  and  consideration  of  the  cardio- vascular  changes 
characteristic  of  that  disease. 

Prognosis. — It  should  be  borne  in  mind  that  in  children  saccharine 
diabetes  has  developed  from  the  insipid  variety.  Diabetes  insipidus  is 
not  incompatible  with  a  fair  degree  of  longevity,  yet  as  a  rule  there  is  a 
general  failure  in  health.  A  neurasthenic  condition  develops  and  the 
patient  succumbs  to  some  intercurrent  disease. 

Treatment. — The  uselessness  of  drugs  in  this  disorder  has  been  demon- 
strated. The  treatment  is  entirely  hygienic.  The  child  must  be  protected 
from  cold,  shock,  and  fatigue.  The  diet  should  be  nutritious,  consisting 
of  a  fair  degree  of  proteids,  with  a  restriction  of  the  carbohydrates. 
Fluids  should  not  be  too  rigidly  restricted,  as  the  unsatisfied  thirst  in- 
duces gastric  derangement  and  wears  out  the  nervous  system.  Free 
diaphoresis  and  catharsis  have  seemed  beneficial.  The  administration 
of  asafoetida — either  in  pill  form  by  mouth  or  as  an  emulsion  by  rectum, 
to  quiet  the  nervous  system  and  stimulate  the  sympathetic  gauglia — is 
worthy  of  trial. 

EHEUMATISM. 

A  consideration  of  the  numerous  theories  as  to  the  etiology  of  rheu- 
matism, however  interesting  or  valuable,  is  precluded  by  the  limited  scope 
of  this  work.  Whatever  may  be  ultimately  demonstrated — and  the  pres- 
ent trend  of  opinion  seems  to  be  strongly  towards  a  microbic  causation — 
for  the  present,  at  least,  the  most  practical  conception  of  this  disorder  is 
that  of  a  diathesis. 

It  may  seem  a  little  old-fashioned  not  to  follow  the  brilliant  bacteri- 
ologists in  their  researches  to  establish  the  identity  of  a  specific  micro- 
organism, but,  admitting  it  to  have  been  found,  until  some  method  of 
protection  against  its  invasion  shall  be  demonstrated,  safety  must  be 
sought  along  the  line  of  demonstrable  clinical  facts.  To  appreciate  rheu- 
matism in  infancy  and  childhood,  the  student  may  well  forget  the  clini- 
cal picture  of  adult  rheumatism.  In  fact,  this  picture  so  long  obscured 
the  view  that,  until  quite  recently,  rheumatism  was  denied  admission  to 
the  diseases  of  infancy  and  early  childhood.  The  heredity  of  the  rheu- 
matic diathesis  is  established  beyond  all  question.  This  is  so  evident  that 
double  heredity  predicts  with  almost  certainty  the  appearance  of  rheu- 
matic manifestations  in  the  children.  Another  well-established  clinical 
fact  is  the  influence  upon  the  system  of  dampness  and  cold  as  an  exciting 
cause. 

It  is  endemic  in  localities  marked  by  sharp  variations  in  temperature 
and  humidity,  high  and  low  altitudes  showing  remarkable  exemption. 


RHEUMATISM  629 

Its  epidemic  character  depends  upon  variations  of  season,  attacks  occur- 
ring with  notable  frequency  in  spring  and  fall.    It  is  principally  seen  in 

the  temperate  zone,  near  large  bodies  of  water,  and  in  low-lying  districts. 

.Malhvgiene  as  to  food,  clothing,  sunlight,  and  pure  air  intensifies  the 
diathesis. 

Neither  sex  nor  age  shows  immunity  that  is  not  explained  by  protec- 
tion from  exposure  to  malhygiene.  Rapidly  accumulating  reports  of 
rheumatism  in  early  infancy  not  only  prove  its  existence,  but  emphasize 
the  modern  conception  of  its  multimanifestations.  It  is  fair  to  assume 
that  some  of  these  manifestations  are  daily  overlooked  or  misinterpreted 
by  practitioners  to  whom  adult  rheumatic  arthritis  is  a  familiar  disease. 

Multiple  arthritis  of  severe  type  has  been  reported  in  an  infant  only 
a  few  days  old,  although  this  form  is  rarely  seen  at  this  early  age.  Fre- 
quently the  joint  affection  is  so  slight  as  to  escape  notice,  careful  examina- 
tion being  necessary  to  reveal  the  affected  part,  which  may  be  neither  red 
nor  swollen,  and  show  only  slight  pain  on  manipulation.  It  may  be 
accompanied  by  a  trifling  rise  in  temperature,  easily  attributable  to  other 
causes. 

Differential  Diagnosis. — The  evidence  of  the  pain  on  handling  may 
be  attributed  to  rhachitis,  and  must  be  differentiated  from  the  sub- 
periosteal pain  of  scorbutus.  The  child  may  limp  a  little  on  his  way  to 
school,  or  rest  from  play  on  account  of  slight  tenderness  in  knee  or  ankle, 
or  stumble  and  fall  from  imperfect  control  of  the  limb.  Upon  examina- 
tion, a  slight  elevation  of  temperature  may  be  found,  with  history  of  pre- 
ceding malaise  or  irritability.  The  child  may  complain  of  discomfort 
in  limbs,  frequently  after  retiring,  perhaps  awakening  in  the  night  from 
pain.  This  is  usually  ascribed  by  the  mother  to  "growing  pains"  or 
muscle  cramps. 

The  myalgias  of  childhood  are  so  common  as  frequently  to  pass  un- 
observed, or  at  least,  if  moderately  persistent,  to  secure  only  the  service 
of  hot  applications.  The  young  infant  must  usually  be  satisfied  with  the 
diagnosis  of  colic.  Severe  muscular  and  arthritic  pains  are,  perhaps, 
the  least  frequent  rheumatic  expressions  in  child  rheumatism. 

Occasionally  forms  are  seen  in  which  multiform  erythemas,  purpuric 
eruptions,  torticollis,  or  subcutaneous  nodules  are  the  only  manifes- 
tations. 

More  common  are  chorea  and  tonsillitis,  but  the  distinguishing  fea- 
tures of  paramount  importance  are  the  cardiopathies.  Whatever  the 
other  rheumatic  symptoms  and  lesions  may  be,  the  heart  rarely  escapes 
involvement.  The  too  prevalent  belief  that  an  endocardial  murmur  or 
a  friction  rub  is  a  necessary  expression  of  cardiac  inflammation  is  an 
expensive  error.  That  myocardial  involvement  may  precede  the  endo- 
carditis or  pericarditis,  or  exist  in  the  absence  of  either  or  both,  is  a  fact 
gaining  daily  in  recognition.  The  insufficiency,  so  frequently  aseribed 
to  the  dilated  ventricle  of  the  developing  period,  is  now  more  commonly 
regarded  as  of  rheumatic  origin. 

The  fact  that  the  cardiac  lesion  is  the  one  common,  constant  expression 


630  GENERAL    DISEASES 

of  child  rheumatism,  in  view  of  the  extent  and  gravity  of  the  results, 
emphasizes  the  importance  of  careful  examination  in  every  case  present- 
ing any  of  these  associated  manifestations  of  a  rheumatic  diathesis. 

Chorea,  muscular  or  arthritic  pain  and  heart  lesion,  have  long  been 
recognized  as  the  tripod  which  supports  the  diagnosis  of  rheumatism 
in  early  life.  These  are  not  always  present  at  the  same  time.  So,  too, 
of  the  other  expressions,  but  one  or  more  may  appear,  although  their 
frequent  association  with  a  cardiac  lesion  is  well  established. 

The  fibrous  nodules,  infrequently  reported  in  this  country,  are  com- 
mon in  England.  They  consist  of  firm,  discrete,  subcutaneous,  nodular 
masses,  appearing  over  the  wrists,  elbows,  patella?,  point  of  the  shoulder, 
scalp,  and  back,  freely  movable  and  usually  painless,  varying  in  size 
from  a  wheat  grain  to  a  filbert.  They  may  be  few  or  numerous  and  may 
disappear  in  a  few  days  or  persist  for  long  periods.  European  observers 
regard  their  appearance  of  grave  import,  suggestive  of  probable  fibrous 
involvement  of  the  peri-  or  endocardium.  Inflammation  of  other  serous 
structures,  meningeal,  pleural,  or  peritoneal,  have  long  been  regarded, 
whether  correctly  or  not,  as  rheumatic,  but  the  proof  of  the  claim  is 
difficult. 

The  duration  of  an  attack  of  rheumatism  may  not  be  stated,  so  vari- 
able is  its  course  and  intensity.  From  six  days  to  six  months  have  been 
reported  as  periods  during  which  the  patient  was  not  free  from  acute 
symptoms.  Probably  attacks  of  moderate  severity  as  to  fever  and  joint 
involvement,  would  average  a  period  of  three  weeks.  During  this  time 
pyrexia  is  fairly  constant,  rarely  exceeding  103°  F.  (39.5°  C).  Ano- 
rexia, present  at  the  beginning  of  an  attack,  is  not  persistent,  the  child 
frequently  begging  for  forbidden  food.  Acid  sweat  of  a  peculiar  odor 
is  a  common  feature ;  respiration  is  accelerated  in  proportion  to  the 
temperature,  but  slow  compared  with  the  pulse.  This  is  usually  rapid 
and  irregular,  arhythmic  or  compressible,  according  to  the  nature  and 
degree  of  cardiac  involvement. 

The  arthritis  involves  the  large  joints — ankle,  knee,  wrist,  and  elbow 
— successively  shifting  (frequently  in  a  few  hours),  with  a  moderate 
degree  of  heat,  pain,  and  swelling,  but  with  exquisite  pain  at  the  slightest 
touch  or  motion. 

Different  joints  may  become  involved  successively,  either  unilater- 
ally or  bilaterally.  Rarely  the  arthritis  is  confined  to  one  articulation. 
Occasionally  in  the  neighborhood  of  the  affected  areas  eruptions  may 
appear,  as  erythema  papillosum,  marginatum,  and  nodosum.  In  some 
cases  the  back  and  chest  may  be  covered  with  sudamina.  Hemorrhagic 
urticaria  is  sometimes  seen ;  also  small  petechia?.  In  fact,  the  hemor- 
rhagic tendency  is  quite  marked  in  severe  forms  of  this  disease,  and 
epistaxis  is  not  uncommon,  with  evidences  of  profound  blood  changes. 
The  haemoglobin  and  red  cells  are  diminished,  while  the  white  cells  and 
fibrin  are  increased. 

Diagnosis. — Mild  or  isolated  manifestations  of  rheumatism  may  be 
overlooked.    At  times  differentiation  must  be  made  from  the  tender,  pain- 


RHEUMATISM  631 

ful  limbs  of  scorbutus,  in  which  the  subnormal  temperature,  with  other 
symptoms  of  the  disease,  should  be  a  guide.  The  polyarthritis,  described 
by  Still,  is  characterized  by  splenic  and  glandular  enlargement  not  com- 
mon to  rheumatism.  The  joint  involvements  in  pyaemia  and  epiphysitis, 
with  fever  and  swelling,  may  for  a  time  simulate  inflammatory  rheuma- 
tism, but  the  recurrent  chills,  early  suppuration,  and  subsequent  history  in 
the  latter,  should  clear  up  all  doubt.  Bone  tuberculosis  may  involve  the 
joint  and  make  the  diagnosis  difficult  at  first.  Tuberculous  hip  disease, 
with  its  early  knee  pain,  should  present  but  little  difficulty,  after  careful 
examinations  for  signs  of  this  lesion.  The  same  may  be  said  of  gonor- 
rhoea! joint  infection,  though  cases  are  reported  of  multiple  purulent 
arthritis  in  infants  who  are  victims  of  the  gonococcus. 

In  children  with  a  rheumatic  heredity,  epiphysitis  of  shoulder,  elbow, 
knee,  or  ankle,  makes  differentiation  extremely  difficult  for  a  time.  Early 
suppuration  clears  the  diagnosis. 

Prognosis. — The  prognosis  depends  upon  the  gravity,  extent,  and 
nature  of  the  heart  involvement.  As  before  mentioned,  rheumatism  is  the 
most  prolific  cause  of  cardiopathies  which,  with  its  predisposition  to  recur- 
rence, may  not  only  cause  death  from  syncope  during  the  height  of  an 
attack,  but  handicaps  the  individual  in  his  struggles  against  other  acute 
diseases. 

Treatment. — Aside  from  the  amelioration  of  pain,  the  treatment 
should  be  entirely  prophylactic  against  the  one  grave  complication. 
Hence  the  necessity  for  an  early  recognition  of  the  diathetic  stigmata. 
Upon  the  first  appearance  of  any  of  these,  however  seemingly  trivial, 
the  child  should  be  put  to  bed.  This  procedure,  although  apparently 
heroic,  is  rational,  in  view  of  the  conservation  of  heart  action  thereby 
obtained.  This  object  should  be  secured  by  all  synergistic  measures.  If 
there  be  painful  arthritis,  the  parts  should  be  swathed  in  cotton  or  wool 
that  has  been  saturated  with  an  embrocation  consisting  of  oleum  gaul- 
theria?,  spiritus  chloroformi,  or  linimentum  saponis,  and  covered  with  pro- 
tectees. The  intoxication,  however  mild,  should  be  combated  by  all 
means  of  approved  efficacy.  Elimination  should  be  aided  by  catharsis, 
diuresis,  and  diaphoresis. 

Calomel  in  one-half  to  one-grain  (0.03-0.065  Gm.)  doses,  with  one 
to  ten  grains  (0.065-0.65  Gm.)  of  sodium  bicarbonate,  should  be  given 
four  times  the  first  day  and  followed  by  salines,  as  magnesium  citrate 
or  sodium  sulphate,  every  two  to  four  hours,  sufficient  to  maintain  free 
liquid  evacuations.  Water  should  be  freely  administered,  preferably 
the  lithia  water,  with  hot  baths  or  packs. 

The  consensus  of  opinion  favors  the  use  of  sodium  and  ammonium 
salicylates,  salicylic  acid,  salacin,  salol.  salophen,  salopirine,  oil  of  win- 
tergreen,  and  aspirin.  An  effort  should  be  made  to  neutralize  the  acidosis 
by  the  free  use  of  alkalies,  such  as  sodium  and  potassium  bicarbonate, 
citrate  and  acetate,  or  fresh  fruit  juices.  Initial  doses  of  sodium  salicyl- 
ate, one  grain  (0.065  Gm.)  for  each  year  of  age,  every  three  hours  in 
syrup  of  gaultheria,  or  half  the  quantity  in  a  drachm  of  five  per  cent. 


632  GENERAL    DISEASES 

emulsion  of  oil  of  wintergreen,  may  be  used.  On  account  of  gastric 
intolerance  for  these  drugs,  their  use  should  not  be  prolonged  beyond  a 
few  days,  except  in  greatly  diminished  doses.  If  necessary,  aspirin  may 
be  substitued  in  similar  doses,  as  greater  freedom  from  gastric  and  toxic 
symptoms  is  claimed  for  this  agent.  Prolonged  heroic  exhibition  of  sal- 
icylates combined  with  alkalies  may  aggravate  or  even  induce  rapid  haemo- 
lysis, and  promote  purpura,  hemorrhagic  symptoms,  epistaxis,  etc.  If 
pain  or  restlessness  be  marked,  relief  must  be  secured  by  the  judicious 
use  of  opiates,  such  as  Dover's  powder,  one  to  five  grains  (0.065-0.32 
Gm.),  or  codeine,  cautiously  administered.  The  prophylactic  value  of 
cardiac  sedation  fully  justifies  the  exhibition  of  opium  in  these  cases. 

The  abatement  of  the  acute  symptoms,  if  such  there  be,  should  not  be 
the  signal  for  allowing  the  little  patient  his  freedom.  On  the  contrary, 
he  must  be  kept  in  bed  to  prevent  relapse  and  damage  to  the  heart,  which 
is  in  all  probability  affected,  though  no  positive  evidence  of  valvular 
lesion  be  apparent.  It  is  better  to  err  on  the  side  of  too  long  detention 
in  bed  than  in  too  early  exposure  to  heart  strain.  The  pronounced 
anaemia  of  rheumatism  requires  the  early  use  of  iron  and  tonics. 
Basham's  mixture,  in  from  five  to  forty  minim  (0.3-2.56)  C.c.j  doses, 
may  be  given  four  times  a  day,  while  moderate  doses  of  quinine  in 
chocolate  or  syrup  of  yerba  santa  is  an  eligible  tonic.  Cream  and  cod- 
liver  oil  are  valuable  during  convalescence. 

If,  in  spite  of  these  measures,  the  heart 's  action  become  rapid,  irregu- 
lar, and  weak,  the  ice-bag  should  be  applied  over  the  precordia  and 
retained,  if  tolerated,  until  cardiac  symptoms  subside.  At  least  one 
thickness  of  flannel  should  be  interposed  between  skin  and  coil,  which 
should  be  shifted  from  time  to  time  to  prevent  chilling.  Warmth  in 
the  extremities  should  be  preserved  by  means  of  hot-water  bottles. 
During  an  attack,  milk  is  the  ideal  diet.  Convalescence  would  warrant 
meat  broths  and  soups,  with  custards,  succulent  vegetables,  plain  pud- 
dings with  cream,  stewed  fruits,  unfermented  grape  juice,  and  lemon- 
ade. The  diet,  as  a  rule,  in  the  rheumatic  diathesis  should  contain 
a  liberal  amount  of  proteids,  carbohydrates  being  limited.  The  prone- 
ness  of  these  children  for  sweets  should  be  remembered  and  guarded 
against. 

The  hygiene  of  the  rheumatic  diathesis  would  require  flannel  of  sea- 
sonable thickness  worn  continuously.  The  child  should  be  gradually 
habituated  to  cold  bathing  as  a  defensive  measure.  After  unavoidable 
exposure  and  during  changes  of  season,  the  child  should  be  put  upon 
salicylate  salts,  or  the  natural  oil  of  wintergreen  in  emulsion,  in  moderate 
doses  for  a  period  of  several  days.  Care  of  the  throat  and  upper  respira- 
tory passages  is  important,  including  the  treatment  or  removal  of  hyper- 
trophied  faucial  and  pharyngeal  tonsils.  The  emunctories  must  be  kept 
active,  and  alkaline  waters  and  fruit  juices  should  form  an  important 
part  of  the  dietary. 


Appendix 

SICK-ROOM  HYGIENE 

The  siek-room  should  be  so  situated  as  to  secure  free  entrance  of  sun- 
light and  the  best  of  ventilation,  also  freedom  from  noise  and  disturb- 
ance. For  these  reasons  an  upper  room  is  preferable.  It  should  be 
plainly  furnished,  with,  washable  hangings.  A  metal  bedstead  is  de- 
sirable, which  should  be  so  placed  as  not  to  face  windows,  and  to  allow 
approach  on  either  side.  The  floor  should  be  bare  except  for  small, 
removable  rugs. 

The  importance  of  ventilation  need  not  here  be  emphasized  further 
than  to  suggest  windows  that  may  be  opened  at  bottom  and  top.  ■  Light 
screens  should  be  used  to  prevent  a  too  strong,  direct  draught.  The  wide- 
open  window,  even  with  wire  screen,  may  be  improved  upon  in  most 
large  cities  by  an  additional  netting  of  gauze  or  cheesecloth,  which  acts 
as  a  dust  filter. 

Where  possible,  great  benefit  may  be  secured  by  carrying  the  patient 
into  another  room  for  a  portion  of  the  day,  while  the  sick-room  is  widely 
opened  to  air  and  sunlight.  In  very  hot  weather  the  temperature  may 
be  notably  reduced  by  pails  or  tubs  of  broken  ice  to  which  salt  is  added, 
and  over  which  an  electric  fan  may  play,  thus  securing  more  complete 
change  of  air.  Stale  air  may  be  removed  by  a  vigorous  swinging  of  the 
door.  Doors  which  are  liable  to  slam  should  be  protected  by  a  towel 
fastened  to  both  knobs,  to  serve  as  a  bumper. 

The  bed  should  have  a  smooth,  level  mattress,  preferably  of  hair  (the 
pillow  should  also  be  of  hair),  and  provided  with  a  rubber  sheet,  linen 
or  cotton  sheets,  and  light  blankets.  A  light,  sick-room  table,  the  top 
of  which  projects  over  the  bed,  is  a  great  convenience  for  older  children 
during  convalescence.  When  not  in  use  for  the  patient  it  may  be  lifted 
to  one  side  and  used  for  medicines  and  appliances,  all  of  which  should 
be  kept  out  of  the  patient 's  sight. 

Facilities  for  heating  water  should  be  close  at  hand,  if  possible  in 
another  room,  unless  an  electric  heater  is  available.  In  houses  lighted  by 
electricity,  appliances — such  as  foot-warmers,  hot  pads,  and  water- 
heaters — are  easily  attached  and  are  a  great  convenience.  Gas-  and  oil- 
burners  and  kerosene  lamps  consume  much  oxygen  and  render  the  air 
of  the  room  impure. 

The  urinal  may  be  a  necessity,  but  the  ordinary  bed-pan  is  a  nuisance, 
against  which  the  majority  of  children  protest.  Unless  especially  contra- 
indicated  by  a  critical  condition  of  the  heart,  a  medical  case,  if  old 
enough   may  be  placed  upon  a  commode,  with  increased  comfort  to  the 

633 


634  APPENDIX 

child  and  more  thorough  evacuation  of  the  bowels.  The  vessel  receiving 
the  discharges  should  contain  a  deodorant  solution — as  bichloride  of 
mercury,  1  :  1000 ;  potassium  permanganate,  1  :  1000 ;  chloride  of  zinc, 
1  :  50 ;  or  a  weak  solution  of  formalin — and  should  be  removed  from 
the  room  immediately  after  use.  Even  older  children  should  be  diapered 
if  there  be  any  possibility  of  involuntary  evacuations. 

Air-cushions  or  hair-pads  are  useful  to  protect  the  bony  prominences 
from  undue  pressure,  and  in  prolonged  sickness  a  water-bed  may  be 
necessary.  A  bent-wood  or  wicker  device  is  useful  for  taking  the  weight 
of  the  bedclothes  off  the  patient's  feet.  By  these  precautions,  and  fre- 
quent bathing  of  the  parts  subject  to  pressure  with  diluted  alcohol,  bed- 
sores may  usually  be  prevented. 

Medicine-cups,  "feeders,"  and  bent-glass  drinking-tubes  are  indis- 
pensable in  the  sick-room.  Cleansing  of  the  patient's  mouth,  both  before 
and  after  feeding,  will  increase  his  comfort  and  lessen  the  danger  of 
further  infection.  For  this  purpose  a  mixture  of  dilute  alcohol  and 
glycerin,  or  an  antiseptic  alkaline  solution,  as  Seller's,  may  be  used. 

The  use  of  a  bed-gown  which  opens  the  full  length  in  front  is  a  great 
convenience  for  both  nurse  and  physician. 

The  nurse  should  be  provided  with  noiseless  slippers,  and  dress  of 
wash  material. 

CONTAGIOUS   DISEASES. 

In  the  management  of  contagious  diseases  strict  quarantine  should 
be  maintained.  A  sheet  suspended  over  the  doorway  should  be  kept 
dampened  with  a  solution  of  bichloride  of  mercury  (1  :2000),  which, 
kept  in  a  pail  for  that  purpose,  may  be  applied  with  a  whisk-broom.  A 
hook  for  the  doctor's  gown  and  cap  may  be  fastened  to  the  jamb  between 
the  door  and  the  sheet.  A  washbowl,  soap,  nail-brush,  antiseptic  solu- 
tion, and  alcohol,  should  be  placed  near  the  door  for  the  use  of  the 
attendant  and  physician. 

Clothes  soiled  with  mucus  or  other  discharges  should  be  thrown  into 
a  slop-jar  containing  bichloride  of  mercury  solution  (1:1000).  Dia- 
pers, towels,  bedlinen,  and  all  clothing  used  in  the  sick-room  should  be 
soaked  in  an  antiseptic  solution  before  being  sent  to  the  general  laundry. 
Granite-ware  is  good  material  for  sick-room  utensils,  as  it  is  light,  un- 
breakable, nonabsorbent,  inexpensive,  and  easily  sterilized. 

Raising  quarantine  should  include  a  thorough  disinfecting  bath  fol- 
lowing one  of  soap  and  warm  water,  paying  special  attention  to  the  nails 
and  hair,  as  these  harbor  infection.  The  child  should  be  freshly  clad  in 
an  adjoining  room.  The  mouth,  throat,  and  nose  should  be  sprayed  with 
Seller's  solution,  which  operation  should  be  repeated  daily  for  some  time 
after  convalescence. 

The  room — including  all  bedding,  clothes,  and  furniture — should  be 
carefully  fumigated  after  the  patient's  removal.  This  is  best  done  by 
evaporating  formalin  from  wet  sheets  suspended  across  the  room,  after 
all  the  cracks  around  doors  and  windows  are  carefully  sealed.  At  least 
a  pound  (500  C.c.)  of  forty  per  cent,  formaldehyde  should  be  used  to 


THERAPEUTIC    SUGGESTIONS  635 

every  thousand  cubic  feet  of  space,  and  the  door  locked  for  twenty-four 
hours.  If  sulphur  is  used  three  pounds  i  l..">  kilos)  should  be  employed 
in  an  ordinary  bed-room.  The  sulphur  may  be  burned  in  an  iron  kettle 
placed  in  a  tub  which  is  partly  filled  with  water.  Half  a  pint  of  alcohol 
should  he  poured  over  the  sulphur  to  secure  ignition.  One  objection  to 
the  use  of  sulphur  is  its  effed  upon  metals  and  colored  fabrics.  Follow- 
ing smallpox  and  scarlet  lever,  mattress  and  pillows  should  invariably 
be  burned. 

After  fumigation,  the  windows  should  be  opened  wide  and  the  room 
and  furniture  thoroughly  scrubbed  with  soap  and  water.  It  should  be 
aired  continuously  for  several  days. 

For  cheap  and  efficient  disinfecting  solutions  see  Formulary. 

THERAPEUTIC    SUGGESTIONS. 

While  functional  disturbances  and  pathological  conditions  are  easily 
induced  in  infants  and  children,  it  should  be  remembered  that  they 
are  as  readily  responsive  to  remedial  agents,  whether  food,  hygienic 
measures,  or  drugs. 

As  in  early  life  spoiled  organs  are  rare,  so,  also,  drug  habits  and  idio- 
syncrasies are  seldom  encountered.  Indeed,  the  response  to  drugs  is 
keener  and  more  satisfactory  than  in  adults.  However,  but  few  drugs 
are  necessary  in  the  proper  care  of  children.  If  polypharmacy  be 
reprehensible  in  the  therapy  of  adults,  it  is  little  less  than  criminal  in 
the  treatment  of  children. 

One  thing  is  evident  and  daily  demonstrable, — viz.,  the  more  thor- 
oughly the  practitioner's  knowledge  of  the  physiology  of  the  developing 
period  the  more  simple  and  efficient  is  his  drug  therapy. 
■  The  oft-repeated  untruth,  that  disorders  in  children  are  relatively 
difficult  of  correction,  is  but  a  confession  of  the  utterer's  unfitness  for 
the  undertaking. 

The  cause  of  much  error  in  the  infant's  treatment  is  the  too  common 
habit  of  regarding  him  as  a  miniature  edition  of  the  adult.  Such  an 
erroneous  conclusion  bears  fruit  in  misguided  efforts  to  apply  thera- 
peutic knowledge,  obtained  from  observations  of  drug  action  in  adults, 
to  the  correction  of  entirely  different  conditions  in  the  infant.  An 
intelligent  manipulation  of  conditions  which  influence  metabolism — 
such  as  temperature,  humidity,  light,  and  air,  with  a  better  under- 
standing of  food  principles,  digestion,  absorption,  and  elimination — 
will  reduce  the  multitude  of  drugs  to  a  very  limited,  safe,  and  efficient 
few.  It  is  apparent  that  the  quantity  of  a  drug  necessary  to  produce 
a  certain  effect  in  an  infant  can  never  be  determined  by  any  mathe- 
matical calculation  based  upon  the  effect  of  the  same  drug  in  an  adult. 
The  dose  of  any  indicated  medicament  must  always  be  enough  to  produce 
the  desired  effect,  and  as  this  varies  widely  in  different  cases  the  initial 
dose  in  any  case  is  largely  experimental ;  hence  common  prudence  sug- 
gests small  doses  repeated  at  short  intervals,  accompanied  by  a  careful 
watch  of  the  results.    For  this  reason  simplicity  in  prescribing  is  of  the 


636  APPENDIX 

utmost  importance  and  the  routine  emplojonent  of  synergists,  adjuvants, 
and  corrigents  should  be  discouraged  as  at  least  confusing,  if  not  detri- 
mental. Infant  absorption  and  excretion  are  notably  rapid, — another 
reason  for  short  intervals  between  the  doses  of  agents  to  be  absorbed. 
This  is  especially  true  of  alkaloids  and  soluble  crystallizable  substances. 
Free  dilution  favors  rapid  absorption,  nor  should  it  be  forgotten  that  a 
catarrhal  condition  of  the  digestive  tract,  or  the  presence  of  food,  may 
conspicuously  retard  absorption.  It  is  known  that  some  alkaloids  are  so 
changed  by  long  contact  with  digestive  secretions  as  to  interfere  with 
their  specific  action. 

Excepting  in  extreme  emergencies  no  remedies  should  be  exhibited 
that  interfere  with  digestion.  The  double  demand  for  nutrition  in  child- 
hood lends  special  emphasis  to  this  caution.  Its  disregard  too  frequently 
makes  the  effects  of  treatment  worse  than  that  *of  the  disease.  The  em- 
ployment of  syrupy  vehicles  for  drugs,  for  children  whose  digestive 
tracts  are  particularly  sensitive  to  the  fermentative  changes  of  saccharine 
material,  is  a  common  illustration  of  this  point.  Flavored  tablets,  re- 
duced to  powder  and  washed  down  with  water,  may  well  replace  the 
objectionable  syrups,  and  rectal  and  hypodermic  medication,  if  tactfully 
employed,  have  many  advantages  over  administration  by  mouth.  Oils 
and  fats,  so  frequently  obnoxious  to  palate  and  stomach,  may  be  intro- 
duced with  a  certain  degree  of  efficiency  by  inunctions  with  thorough 
massage.  Quinine,  mercury,  iodine,  and  potassium  iodide,  as  well  as 
silver  and  iodoform,  may  be  introduced  in  this  way  by  incorporation 
with  a  vehicle  rich  in  oleic  acid.  For  this  purpose  lanolin  possesses  the 
highest  value  and  vaseline  probably  the  lowest. 

Rectal  suppositories  of  cacao-butter  furnish  valuable  means  for  the 
administration  of  medicinal  extracts  and  alkaloids,  as  well  as  for 
nutrients  and  evacuants. 

MASSAGE. 

The  value  of  massage  is  too  frequently  overlooked.  Metabolism  in 
infancy  demands  the  excessive  muscular  activity  so  common  to  growing, 
healthy  mammals.  Enforced  quiescence  of  the  sick-room  may  interfere 
seriously  with  the  distribution  of  pabulum  and  the  elimination  of  waste 
products.  Timely,  systematic  massage  will  do  much  to  maintain  these 
important  functions,  as  well  as  to  prevent  hypostasis  from  long-continued 
decubitus. 

LUMBAR    PUNCTURE. 

Lumbar  puncture,  as  a  means  both  of  diagnosis  and  treatment,  is 
so  important  a  procedure  that  a  few  words  concerning  its  technique  may 
not  be  superfluous. 

The  site  of  the  puncture  is  preferably  the  interval  between  the  third 
and  fourth  lumbar  vertebra?  which  lies  practically  in  a  straight  line 
connecting  the  iliac  crests  (Fig.  217).  The  skin  over  this  area  should  be 
cleansed  as  for  a  surgical  operation.     Sharp  antiflexion  of  the  child's 


EYDROTHERAPY  637 

spinal  column,  by  separating  the  processes,  facilitates  the  puncture.  The 
smallest   trocar,   or   a   Large   hypodermic    needle,    previously   sterilized, 

should  be  introduced  in  the  median  line  ;i1  righl  angles  to  the  surface 
(in  older  children  incline  slightly  upwards),  to  the  depth  of  one  and 
one-half  to  two  and  one-half  centime!  iv>  ( three-fifths  to  one  inch;. 

Aspiration  is  contraindicated,  hence  the  syringe  n« •« •<  l  not  be  attached. 
The  escaping  fluid  may  be  collected  in  a  sterile  test-tube  of  beaker  for 
examination.  The  force  of  outflow  should  be  noted,  as  indicative  of  the 
degree  of  pressure.  The  flow  may  be  prevented  by  occlusion  of  the 
needle,  in  which  case  it  should  be  reintroduced  after  cleansing. 

As  a  rule  anaesthesia  is  not  necessary,  although  some  physicians 
prefer  the  local  use  of  ethyl  chloride.  The  child  should  be  held  firmly 
in  the  flexed  position  on  his  side  to  facilitate  puncture  and  prevent 
accident. 

The  quantity  of  fluid  withdrawn  should  depend  upon  the  amount  of 
pressure  as  indicated  by  the  force  of  the  stream  or  the  subsidence  of  the 


Fig.  217.— Lumbar  puncture. 

fontanelle,  if  that  be  open.  A  quantity  of  from  ten  to  thirty  cubic  centi- 
metres (2y2  to  8  drachms)  is  certainly  within  the  limits  of  safety. 
Much  larger  amounts  are  frequently  withdrawn  without  apparent  bail 
effect.  For  purposes  of  examination  the  first  few  drops,  which  usually 
contain  blood  from  the  superficial  capillaries,  should  be  rejected. 

Upon  withdrawal  of  the  needle  the  wound  should  be  sealed  by  collo- 
dion dressing. 

HYDROTHERAPY. 

HOT    PACK. 

The  child  should  be  enveloped  in  a  small  blanket  or  Turkish  towel 
wrung  out  of  water  as  hot  as  can  be  borne,  and  the  whole  covered  with  a 
rubber  sheet.  Ice  or  cold  cloths  should  be  applied  to  the  head.  and.  if 
necessary,  a  hot-water  bottle  to  the  feet.  The  pack  may  be  renewed  in 
thirty  or  forty  minutes  if  necessary. 


638  APPENDIX 

COLD   PACK. 

The  trunk  only  should  be  enveloped  in  a  sheet  or  towel  wrung  out  of 
water  at  a  temperature  of  80°  to  90°  F.  (27°-32°  C),  and  covered  with 
a  light  flannel  blanket.  Cold  should  be  applied  to  the  head  and  heat  to 
the  feet  and  limbs.  This  pack  may  be  renewed  in  from  thirty  minutes 
to  an  hour,  according  to  effect  upon  the  child's  temperature  and  circu- 
lation. The  ice-cap  to  the  head  alone  is  frequently  sufficient  to  reduce 
temperature. 

SPONGE   BATH. 

The  child,  stripped  and  laid  on  a  blanket,  should  be  sponged  with 
water  to  which  twenty-five  per  cent,  of  alcohol  or  vinegar  has  been 
added.  For  warm  sponging,  water  at  a  temperature  of  100°  to  105° 
F.  (38°-40.5°  C.)  may  be  used.  For  cool  sponging  it  may  be  reduced 
to  90°  or  even  60°  F.  (32°-15.5°  C.)  according  to  comfort.  A  light 
blanket  should  cover  the  child,  so  that  only  a  small  portion  of  the 
body  be  exposed  at  one  time,  or  the  entire  bath  may  be  given  under 
the  blanket.  In  all  cases,  cold  to  the  head  and  heat  to  the  feet  should 
be  used. 

To  secure  the  effect  of  cold  without  the  pronounced  shock  of  direct 
contact,  the  child  may  be  covered  with  a  sheet  wet  with  water  at  a  tem- 
perature of  100°  F.  (38°  C.)  over  which  pieces  of  ice  are  rubbed.  The 
friction  also  stimulates  circulation  and  promotes  reaction.  The  cool  air 
bath  may  be  applied  by  means  of  a  fan,  electric  or  otherwise,  which 
promotes  rapid  evaporation  from  the  surface  of  moistened  gauze,  two 
thicknesses  of  which  envelop  the  child's  body  and  limbs.  Moisture  is 
maintained  by  sprinkling,  from  time  to  time,  with  warm  water  and 
alcohol. 

TUB    BATH. 

In  tubbing,  the  child  should  be  suspended  in  a  blanket,  hammock 
fashion,  and  lowered  into  the  water  at  100°  F.  (38°C.)  or  more  to  pre- 
vent shock.  By  the  addition  of  cold  water  or  ice  outside  the  blanket  the 
temperature  may  be  reduced  as  much  and  as  rapidly  as  desirable, 
although  rarely  advisable  to  go  below  75°  F.  (24°  C).  Meanwhile, 
friction  should  be  applied  to  body  and  limbs  by  the  busy  hands  of  the 
attendants.  The  wisdom  of  using  the  cold  bath  in  young  and  nervous 
children  is  questionable.  Reaction  should  be  carefully  watched  and  the 
time  should  rarely  exceed  five  minutes.  Upon  removal  from  the  tub  the 
child  should  be  quickly  rolled  in  a  dry  blanket,  without  rubbing. 

HOT    MUSTARD    BATH. 

A  mustard  bath  is  made  by  the  addition  of  a  tablespoonful  of  mus- 
tard to  the  gallon  of  water.  The  temperature  may  be  about  105°  F. 
(40.5°  C.)  and  should  never  exceed  110°  F.  (43°  C).  This  may  be 
administered  as  a  general  bath  in  the  tub  or  only  as  a  foot  bath  in  a 
deep  bowl  or  pail. 


INTERNAL    USE    OF    WATEB  639 

VAPOB    BATH. 

The  hot  vapor  bath  Eor  young  children  and  infants  should  always  be 
administered  in  bed,  the  covering  of  which  is  raised  and  supported  above 
the  child's  body  <>n  a  framework  of  half-hoops  or  a  "cradle."  The 
clothes,  however,  should  be  securely   fastened  aboul    th<-  child's  neck. 

[nto  this  air-space  may  be  introduced  steam  from  a  teakett) ataining 

boiling  water,  or  from  a  vessel  of  water  in  which  red-hoi  bricks  or  irons 
arc  gently  dropped.  Tuley's  apparatus  for  hot  air  bath  consists  of  an 
ordinary  lamp  (placed  on  the  floor)  over  which  is  a  funnel  supported  on 
four  legs.  From  the  top  a  tin  tube  with  elbows  conveys  the  heal  and 
vapor  of  combustion  beneath  the  bedclothes.  The  free  perspiration  in- 
duced by  the  hot  vapor  may  occasion  great  depression,  so  that  the  pulse 
must  be  carefully  watched. 

A  tepid  bath  is  given  at  a  temperature  of  95°  to  100°  F.  I  35°-38°  C). 

BRAN   BATH. 

A  bran  bath  is  given  with  tepid  water  into  which  a  stout  gauze  or 
coarse  muslin  bag,  containing  a  quart  of  wheat  bran,  is  repeatedly 
dipped  and  squeezed  until  the  water  is  milky. 

SHOVTER    BATH. 

The  cold  shower  bath  as  a  tonic  and  invigorator  should  be  given  in 
the  morning,  before  breakfast,  and  should  not  be  prolonged  beyond  one 
minute.  The  child  should  stand  in  warm  water  covering  the  feet,  while 
water  of  a  temperature  of  60°  to  75°  F.  (15.5°-21°  C.)  is  sprayed,  or 
squeezed  from  a  large  sponge  over  shoulders  and  trunk.  Brisk  toweling 
with  friction  should  immediately  follow  to  secure  reactionary  glow  to 
the  skin.  Goose-flesh  or  blueness  contraindicates  cold  affusions.  The 
same  precautions  apply  to  the  dip  or  plunge  baths. 

INTERNAL    USE    OF    WATER. 

"Water,  plain  or  medicated,  is  used  in  irrigations  of  nose,  throat,  ear, 
stomach,  bladder,  vagina,  rectum,  and  colon.  Bland  solutions  of  salines 
and  alkalies,  which  slightly  exceed  the  specific  gravity  of  water,  are  less 
irritating  to  mucous  surfaces  than  plain  water. 

NASAL    IRRIGATION. 

Xasal  irrigation  is  best  accomplished  in  young  infants  while  the  child 
is  lying  on- his  side,  with  the  arms  confined  by  a  large  towel  or  sheet. 
The  syringe  should  have  a  blunt,  soft  rubber  tip  that  will  occlude  the 
nostril  without  abrading  the  mucous  membrane.  While  the  head  is 
steadied  by  gentle  pressure  of  the  hand,  the  fluid  is  slowly  forced  into 
the  upper  nostril  that  gravity  may  promote  its  outflow  from  the  opposite 
side  of  the  nose  (Fig.  218V  The  infant's  crying  favors  the  thorough 
irrigation.     It  is  better  to  force  a  plug  backward  into  the  pharynx  than 


640 


APPENDIX 


forward  by  pressure  from  behind,  as  in  the  latter  case  fluids  and  secre- 
tions may  be  forced  into  the  Eustachian  tube  to  the  detriment  of  the 
middle  ear.  Older  children  may  receive  nasal  irrigation  while  sitting  or 
standing.  The  head  being  inclined  forward  favors  free  circulation 
through  the  posterior  nares  and  exit  by  the  opposite  nostril.  For  this 
purpose  the  syringe,  nasal  douche,  or  irrigator  may  be  used. 


Fig.  218.— Nasal  feeding 


LAVAGE. 

Gastric  irrigation,  or  lavage,  is  best  performed  in  infants  by  means 
of  a  No.  10  or  No.  12  double-eyed  flexible  catheter.  This  is  connected  by 
a  short  glass  tube  with  a  piece  of  rubber  tubing  two  feet  long,  termi- 
nating in  a  funnel.  During  the  process  the  child's  hands  and  arms 
should  be  pinioned  by  a  sheet  while  it  is  held  in  the  arms  of  an  assistant. 
The  catheter,  first  wet,  is  passed  quickly  through  the  fauces  for  a  dis- 
tance of  six  inches  (15  Cm.)  into  the  stomach.  After  allowing  the  escape 
of  any  contained  gas,  the  irrigating  fluid  should  be  cautiously  poured 
into  the  funnel,  which  should  be  held,  at  first  not  more  than  three  or 
four  inches  (7.5-10  Cm.)  above  the  child's  head.  When  the  stomach  is 
filled,  or  before,  if  vomiting  occur,  the  funnel  should  be  lowered  to 
empty  the  stomach,  the  tube  acting  as  a  siphon.  After  this  it  may  be 
filled  as  before,  and  tbe  process  repeated  until  the  fluid  runs  clear.     If 


LAVAGE— GAVAGE— ENEM  A  041 

the  tube  become  occluded  by  solid  particles,  it  may  liave  to  be  with- 
drawn, which,  like  the  introduction,  should  be  done  quickly,  to  avoid 
irritation  of  the  fauces. 

GAVAGE. 

Feeding  by  the  stomach  tube  is  sometimes  necessary  when  a  child 
shows  disinclination  or  inability  to  swallow.  If  vomiting  be  excited  by 
irritation  of  the  throat,  or  if  for  any  reason  its  introduction  be  difficult, 
the  tube  may  be  passed  through  the  nose  into  the  oesophagus,  as  a  child 
fed  in  this  manner  will  frequently  retain  the  food  (Fig.  218). 

IRRIGATION   OF   THE    VAGINA. 

In  vaginal  irrigations,  the  small  glass  catheter  with  multiple  open- 
ings, forms  the  best  tip,  as  it  is  easily  sterilized,  and  the  possibility  of 
extension  of  the  gonorrhceal  infection  must  never  be  lost  sight  of. 

ENEMA. 

Enemata  may  be  given  through  any  sterile  tube  of  proper  calibre, 
•care  being  taken  to  introduce  the  tip,  especially  if  it  be  inflexible,  in  a 
direction  parallel  to  the  anal  outlet,  in  order  to  avoid  wounding  the 
mucous  membrane  (Fig.  219).  The  best  position  for  this  purpose  is  with 
the  infant  lying  across  the  nurse's  lap  face  downwards. 

For  evacuation  of  the  rectal  contents  from  one  to  three  ounces  (30- 
90  C.c.)  is  usually  sufficient.  For  this  purpose  soapy  water  is  appro- 
priate. If  pure  glycerin  be  used  half  an  ounce  (15  C.c.)  will  suffice  and 
may  be  introduced  by  a  hard  rubber  syringe. 

Nutrient  enemata,  to  be  retained,  are  best  administered  after  a  colonic 
flushing  with  free  evacuation.  To  this  end  the  quantity  of  food  should 
rarely  exceed  four  to  six  drachms  (15-23  C.c).  It  may  be  necessary  to 
follow  its  introduction  with  firm  pressure  upon  the  anus  for  a  few 
minutes  to  secure  retention.  Predigested  foods,  such  as  peptonized  milk, 
or  raw  meat  juice,  salted  egg-water  and  whey,  may  be  used  in  this  way. 

COLONIC    FLUSHING. 

Colonic  flushing  requires  the  use  of  a  long  flexible  tube,  as  a  No.  10 
or  No.  14  rubber  catheter,  attached  by  a  glass  connection  to  the  hose  of  a 
fountain  syringe.  The  best  position  for  infants  is  across  the  nurse's  lap, 
which  should  be  protected  by  a  rubber  sheet  (Fig.  219).  After  the  point 
of  the  catheter,  well  lubricated,  is  introduced,  the  fluid  should  be  turned 
on,  as  the  stream  will  facilitate  passage  of  the  flexible  tube  over  the  rectal 
ruga?  and  folds  of  the  sigmoid.  The  height  of  the  fountain  above  the 
body  should  rarely  be  more  than  twelve  to  eighteen  inches  t:>()-4(i  Cm.  I, 
since  if  introduced  too  rapidly  active  peristalsis  will  be  excited.  The 
catheter  should  be  gently  introduced  its  full  length.  II'  it  double  on 
itself,  it  must  be  reintroduced.  Thorough  flushing  may  be  facilitated  by 
elevating  the  buttocks  and  by  gentle  massage  of  the  abdomen  in  reverse 

41 


642  APPENDIX 

course  of  the  descending  colon.  From  one  to  four  pints  (%-2  litres), 
according  to  the  age  of  the  child,  may  be  used  in  this  way.  Ordinarily 
normal  salt  solution  is  most  suitable  for  colonic  flushing,  although  various 


Fig.  219.— Colonic  flushing. 

medicated  solutions  may  be  employed  according  to  the  indications  of  the 
special  case. 

DIETARY. 

BARLEY-WATER    OR    GRUEL. 

Pour  a  pint  of  cold  water  over  a  tablespoonful  of  washed  pearl 
barley;  boil  for  two  hours,  adding  boiling  water  as  needed  to  maintain 
the  pint ;  add  a  pinch  of  salt ;  strain  and  keep  on  ice.  In  the  prepa- 
ration of  infant's  food,  glass,  porcelain,  or  granite  vessels  only  should 
be  used. 

For  gruels  of  oatmeal,  cracked  wheat,  and  other  cereals,  except  rice, 
the  same  method  may  be  used. 

RICE-WATER. 

Macerate  one  ounce  of  well-washed  rice  in  a  quart  of  water  for  three 
hours  at  a  gentle  heat ;  boil  slowly  for  one  hour,  adding  boiling  water  to 
make  up  the  quart  as  evaporation  requires.    Strain  and  keep  on  ice. 

These  gruels  may  be  slightly  sweetened  and  flavored  with  lemon  peel 
or  extract,  if  desired. 

Jellies  are  merely  concentrated  gruels.    When  the  finely  ground  flour 


DIETARY  (i4:J 

of  barley,  oatmeal,  or  rice  are  used,  thirty  minutes'  boiling  will  suffice. 
Cereal  fluids  arc  partially  dextrin  izcd  by  the  addition  of  a  teaspoonful 
of  thick  extract  of  malt,  when  cooled  enough  to  taste. 

EGG-WATER. 

Stir  the  white  of  one  egg  in  six  ounces  of  cool  water;  si  tain  through 
cheesecloth,  adding  a  pinch  of  salt.  For  older  children,  sugar  and  slices 
of  lemon,  or  nutmeg  may  be  added  for  taste. 

CLAM-BROTH. 

Wash  six  large  clams  in  shells;  put  in  kettle  with  eight  ounces  of  cold 
water;  boil  one  minute;  pour  off  and  give  warm.  A  teaspoonful  of 
pulverized  cracker  crumbs  may  be  added,  with  a  little  butter  and  salt  to 
taste. 

CHICKEN-BROTH. 

A  small  chicken,  or  half  of  a  large  fowl  (with  skin  and  fat  removed), 
is  chopped,  bones  and  all,  and  placed  in  a  stewpan  with  a  quart  of  cold 
water  and  a  teaspoonful  of  salt.  Cover  closely  and  allow  to  simmer  for 
two  hours.  After  boiling  for  five  minutes,  remove  from  fire  and  let  it 
stand  covered  for  half  an  hour.  Skim  off  the  fat  and  strain  through 
a  sieve  or  cloth. 

For  chicken  jelly,  allow  more  water  to  evaporate,  strain  into  a  mold, 
and  place  on  ice. 

BEEF-BROTH. 

Mince  a  pound  of  lean  beef ;  put  it  with  its  juice  in  an  earthen  vessel 
containing  a  pint  of  tepid  water.  Add  a  little  salt  and  let  it  stand  for 
one  hour;  strain  through  muslin  until  all  juice  is  removed;  place  this 
liquid  on  the  fire  and  stir  briskly  while  slowly  heating  to  the  boiling 
point,  after  which  remove  at  once ;   cover  and  place  on  ice. 

MUTTON-BROTH. 

To  a  pound  of  lean  mutton  add  three  pints  of  water  and  boil  gently 
for  an  hour,  adding  a  little  salt.  Strain  into  a  bowl,  and  when  cold, 
skim  off  the  fat.    Serve  warm. 

OYSTER-BROTH. 

Cut  into  small  pieces  a  pint  of  oysters;  add  half  a  pint  of  cold  water 
and  allow  to  simmer  gently  for  ten  minutes.  Skim,  strain,  and  add  salt 
and  pepper. 

SCRAPED    OR    PULPED    RAW    MEAT. 

With  a  dull  knife  scrape  the  pulp  of  lean  meat  from  the  connective 
tissue,  salt  to  taste,  and  give  raw.  A  tablespoonful  may  be  given  to  a 
year-old  child. 

The  beef  pulp  may  be  slightly  broiled  and  given  warm,  if  preferred. 


644  APPENDIX 

RAW   MEAT    JUICE. 

A  steak  from  a  leg  of  mutton  or  round  of  beef,  three-quarters  of  an 
inch  thick,  should  be  quickly  seared  in  hot  pan  or  on  broiler;  remove 
and  extract  the  juice  with  a  lemon-squeezer  or  meat-press;  add  a  little 
salt,  and  serve  without  heating.  This  may  be  given  in  quantities  up  to 
a  tablespoonful,  diluted  with  water  or  other  liquid  food. 

Another  method:  To  four  parts  of  minced  lean  meat  add  one  part 
of  cold  water;  cover  and  allow  to  stand  for  one  hour,  stirring  occasion- 
ally ;  after  this  squeeze  through  a  meat-press  and  strain ;  ■  add  salt,  and 
feed  as  above.    Meat  juice  should  always  be  freshly  prepared. 

WHEY. 

Into  a  pint  of  fresh  milk,  slightly  warmed,  stir  a  teaspoonful  or  two  of 
Fairchild's  essence  of  pepsin,  or  its  equivalent  in  liquid  rennet,  or  one 
dissolved  junket  tablet.  Let4it  stand  until  coagulation  occurs  (about 
twenty  minutes),  then  cut  up  the  curds  with  a  knife  and  strain  through 
a  double  thickness  of  sterilized  gauze  or  cheesecloth,  without  pressure. 
(A  pint  of  milk  should  furnish  from  eight  to  twelve  ounces  of  whey.) 
If  the  whey  is  to  be  mixed  with  milk  or  cream,  it  should  be  first  heated 
to  150°  F.  (65.5°  C.)  in  order  to  kill  the  rennet  enzyme.  If  heated 
above  155°  F.  (68°  C.)  the  lactalbumin  is  liable  to  coagulation. 

JUNKET — SWEET    CURD   FOR    OLDER    CHILDREN. 

In  the  above  process  the  curd  may  be  sweetened  and  flavored  and  used 
for  food,  or  the  milk,  treated  with  rennin,  may  be  poured  into  custard 
cups.  Sweetening  and  flavoring  may  be  added  to  the  milk  before  the 
rennin. 

EGG   JUNKET. 

An  egg  beaten  into  a  froth  and  sweetened  with  a  teaspoonful  of  sugar 
may  previously  be  added  to  the  milk  in  the  above,  thus  increasing  the 
food  value. 

LIME-WATER. 

Into  a  pitcher  of  water  put  a  piece  of  unslaked  lime  the  size  of  a 
walnut ;  stir  thoroughly ;  allow  to  settle ;  decant  into  a  bottle  and 
stopper. 

CREAM    OP    TARTAR   LEMONADE. 

Juice  of  one  lemon,  three  or  four  teaspoonfuls  of  granulated  sugar, 
five  grains  of  cream  of  tartar,  and  eight  ounces  of  water.  Shake  thor- 
oughly and  strain. 


FORMULARY  645 


FORMULARY 
DISINFECTING    SOLUTIONS 

No.  1.  5  %  Solution  of  Carbolic  Acid. 

No.  2.  1  :  1000  Solution  of  Bichloride  of  Mercury. 

No.  3.  1  :  1000  Solution  of  Potassium  Permanganate. 

No.  4.  2  %  Solution  Chloride  of  Zinc. 

Xo.  5.     Saturated  Solution  of  Fresh  Lime. 

(One  pound  of  unslaked  Lime  to  four  gallons  of  water.) 

No.  6.     Dry  Chloride  of  Lime. 

No.  7.     iy2  %  Solution  of  Sulphate  of  Copper. 
(One  pound  to  eight  gallons  of  water.) 

No.  8.     6  %  Solution  of  Sulphate  of  Iron. 

(One  pound  to  two  gallons  of  water.) 

For  disinfecting  Hands,  etc. — After  scrubbing  with  soap  and  water, 
use  No.  1  diluted  with  an  equal  quantity  of  water,  No.  2,  or  No.  3, 
remembering  that  the  last  leaves  a  transient  stain  on  the  skin  and  a 
more  permanent  one  on  fabrics. 

For  disinfecting  White  Clothing. — Use  No.  1,  preferably  hot,  No.  2, 
or  No.  4. 

For  disinfecting  Instruments  and  Dishes. — Use  No.  1,  hot. 

For  disinfecting  Discharges. — Any  of  the  above. 

For  Cesspools,  Drains,  Water-closets. — Nos.  3,  1.  5,  6,  7,  or  8. 

It  should  be  remembered  that  hot  soapsuds  is  a  very  efficient  cleansing 
agent.  Continuous  boiling  for  an  hour,  baking  in  a  hot  oven,  or  steaming 
in  an  Arnold  sterilizer,  is  usually  sufficient  to  insure  sterility. 

No.  9.  For  Atomization. 

To  the  ounce  (30  C.c.)  of  albolene  or  lavolene  add  either  one  drop 
(.06  C.c.)  of  pure  carbolic  acid,  one-third  of  a  grain  (.022  6m.)  of 
thymol,  one  or  two  grains  (.06-13  Gm.)  of  menthol,  or  one  or  two 
minims  (.06-.12  C.c.)  of  eucalyptol. 

No.  10.  For  Evaporation. 

To  the  pint  (500  C.c.)  of  boiling  water  add  either  one  drachm  (3.75 
C.c.)  of  benzoin  tincture,  half  drachm  (2  C.c.)  of  eucalyptol,  or  the  same 
quantity  of  terebene  or  creosote. 


646 
No.  11. 


APPENDIX 


No.  12. 


No.  13. 


No.  14. 


No.  15. 


No.  16. 


Mouth-Wash 

and  Spray 

Seller's  Solution. 

Sodium  bicarbonate  gss 

2 

Sodium  biborate 

3ss 

2 

Sodium  benzoate 

gr.lt 

08 

Sodium  salicylate 

gr.lj 

08 

Eucalyptol 

gr.  ss 

04 

Thymol 

gr.  ss 

04 

Menthol 

gr-    i 

02 

Oil  gaultheria 

gtt-  J 

02 

Glycerin 

%  ss 

15 

Alcohol 

3i 

4 

Water,  to  make 

Oi 

500 

Mouth-Wash  and  Spray. 
DooelVs  Solution. 


Sodium  biborate  3i 
Sodium  bicarbonate  £i 
Carbolic  acid  Tt^xxxviii 

Glycerin 
Water,  to  make 


3iv 

3viii 


41 
4| 
2 

15 
250 


No.  11 


ASTRINGENTS. 

1.  Tannic  Acid. 

2.  Alum. 

3.  Zinc  Sulphate. 

4.  Zinc  Sulphocarbolate. 

5.  Silver  Nitrate. 

6.  Protargol. 

7.  Adrenalin. 

Glycerite  op  Tannin. 
Tannic  acid  1  part,  glycerin  4  parts. 

Glycerite  of  Iodine. 
Iodine  5,  potassium  iodide  10,  glycerin  to  100. 

A  GARGLE  TO   PREPARE  THE  THROAT  FOR 
TONSILLOTOMY. 

Boric  acid 

Potassium  bromide  aa  gr.  xx    13 

Water  gi         30 

ANODYNE   SPRAYS   USED   IN   TUBERCULAR 
LARYNGITIS. 

1.  Menthol,  per  cent.  1 

2.  Adrenalin  1  :  1000 

3.  Cocaine,  per  cent.        1  to  2 


FORMULARY 


647 


No.  18. 


No.  19. 

No.  20. 


No.  21. 


No.  22. 


No.  23. 


No.  24. 


No.  25. 


No.  26. 


No.  27. 


Asperin    (Acetyl  Salicylic  Acid). 
Dose:    Gr.  i.    (.065  Gm.)   for  each  year  of  age  for  the  first 
five  years. 

Antipyrin  5%  Solution. 

Sodium  Bromide  gr.  i        1065 

Syr.  Lactucarium  (Aubergier)  n^xv      1 

Sodium  Bromide  gr.  ii       113 

Syr.  Prunus  Virginia  3ss        2 

Syr.  Lactucarium  (Aubergier)  3ss        2| 

Sodium  Bromide  gr.  v       13 

Syr.  Lactucarium  (Aubergier)  3i         4| 


For  Pertussis. 

Tr.  Belladonna  n\jii 

Sodium  Bromide  gr.  iii 

Syr.  Lactucarium  ad.   ^i         4 

For  a  child  of  one  year,  every  4  to  6  hours,  if  necessary. 

INFANT    CORRECTIVES. 


Calomel  gr.  fa 

Ipecac  Powder  gr.  fa 

Sodium  Bicarbonate  gr.  £ 
Bismuth  Subnitrate  gr.  1 
Oil  of  Anise  n^  fa 

Calomel  gr.  fa 

Ipecac  Powder  gr.  fa 

Sodium  Bicarbonate  gr.    1 

Calomel  gr.   \ 

Ipecac  Powder  gr.  fa 

Sodium  Bicarbonate  gr.    1 


0032 

0013 

032 

065 

003 

0065 
0032 
065 

013 
006 
065 


For  Relief  of  Asthma. 
Paper  saturated  with  a  solution  of  Potassium  Nitrate,  and 
dried,  may  be  burned  with  the  powdered  leaves  of  Stramonium 
and  the  fumes  inhaled. 


No.  28. 


No.  29. 


Anderson's  Dusting  Powder. 

Powdered  Starch  3V'        231 

Zinc  Oxide  %\  ss        6 

Powdered  Camphor  3ss  2| 

Bland  Dusting  Powder. 

Zinc  Oxide  3»  81 

Powdered  Lycopodium  Seeds  jjvi       23| 


648 
No.  30. 


APPENDIX 


Xo.  31. 


Xo.  32. 


No.  33. 
Xo.  34. 
Xo.  35. 

Xo.  36. 


Xo.  37, 


Xo.  33. 


Lassar  's 

Paste. 

Salicylic  Acid 

gr.  x 

Zinc  Oxide 

3" 

Powdered  Starch 

3" 

Petrolatum 

gss 

Lassar 's  Paste 

Modified. 

Zinc  Oxide 

3i! 

Talcum 

oiv 

Salicylic  Acid 

gr.  x 

Vaseline 

5  ss 

'65 


16 


65 


3iv 

15 

3  vis 

s     25 

51 

30 

Oii 

1000 

15| 
Varnish  for  Eczema. 

Zinc  Oxide 
Gelatin 
Glycerin 
"Water,  to 

Carbolized  Vaseline  2  to  10  %. 
Bora  ted  Lard  10  %. 

Mixed  Fats  {EusselVs  Emulsion) . 

Equal  parts  of  Beef  Fat,  Cocoanut,  Peanut,  and  Olive  Oils,, 
with  two  drops  of  Clove  Oil  to  each  ounce  of  emulsion. 

RUBEFACIENTS. 

1.  Camphorated  Oil. 

2.  Turpentine  and  Oil  or  Lard,  1  : 4. 

3.  Mustard,  mixed  to  a  paste  with  cold  water  or  white  of  egg. 

Mustard  and  flour,  from  1  :  6  parts,  and  water  to  make  a 
paste. 

4.  Capsicum  10  parts,  Oil  of  Mustard  1  part,  Croton  Oil  1  part, 

and  Vaseline  20  parts. 

Milk  of  Asafetida. 
Tincture  of  Asafetida  and  water  (1  :  20),  used  as  an  enema.. 


Simola  Mixture  Modified. 

Sodium  Iodide         gr.  iss 
Sodium  Phosphate  gr.  iii 
Sodium  Chloride      gr.  x 
Water,  to  5  iv    120 


INDEX 


Abdomen,  at  birth,  34 

Abdominal  bands,  136;  tuberculosis, 
599 

"  Abiotrophy,"  457,  4G0 

Abscess,  brain,  441;  etiology,  441; 
surgery  in,  443;  psoas,  512;  pul- 
monary, 355;  diagnosis,  356; 
retro-cesophageal,  235;  retro-pha- 
ryngeal,  55,  230,  512;  tuberculous, 
597 

Accessory  thyroid  gland,  34 

Achondroplasia,  164,  186 

Acid  albumin,  -73;  hydrochloric,  66, 
73  to  76;  lactic,  66,  92;  phospho- 
carnic,  92;  sulphuric,  in  milk 
testing,  102 

Acrania,   150 

Acute  yellow  atrophy,  286 

Addison's  disease,  490 

Adenia,  485 

Adenitis,  4S0;  acute  simple,  482; 
chronic,  485;  gastric,  241;  in 
Hodgkin's  disease,  485;  primary, 
482;  treatment  of,  484;  tuber- 
culous, 59S 

Adenoid  vegetations,  224;  examina- 
tion for,  228;  facies,  226;  habit, 
228;  in  tuberculosis,  229;  treat- 
ment of,  229 

Adipositas,  199 

Adrenalin^  507,  510 

Adrenals,  at  birth,  38;  blood  supply, 
38;  disorders  of,  489;  apoplexy, 
490  ;  hemorrhages,  489 ;  symptoms, 
490 

Adriance,   93,   113 

"  Agenesis  corticalis,"  447 

Ahlfeld,  96 

Air  hunger,  319 

Albinism,  156 

Albumen,  128 


Albuminoses,  73 

Albuminuria,  at  birth,  67;  cyclic,  368; 
extra-renal,  369;  frequency  of,  in 
childhood,  369;  functional,  368; 
in  diphtheria,  570;  in  summer 
diarrhoea,  250;  intermittent,  368; 
physiological,  postural,  368 

Alimentary  tract,  at  birth,  35;  develop- 
ment of,  35,  55 

Alkalinity  in  infant  food,  115 

Amaurotic  family  idiocy,  459;  etiol- 
ogy, theories  of,  460;  eye-ground 
in,  460;  symptoms,  460 

Amblyopia,  congenital,  156 

Amniotic  bands,  154 

Amputation,  intra-uterine,  154 

Amyloid  degeneration,  287;  of  kidney, 
378 

Amylopsin,  74 

Anaemia,  blood  in,  causes  of,  498; 
diagnosis,  499 ;  haemanalysis  in, 
499;  in  Hodgkin's  disease,  486; 
in  malaria,  583;  pernicious,  501, 
502;  pseudoleukaeniic.  506; 
splenic,  489;  susceptibility  in  in- 
fancy, 498;  symptoms  of,  499; 
treatment  of,  500 

Anal  atresia,  159 

Analgesia  in  syringomyelia,  472 

Anastomosis  of  nerves,  175;  of  ten- 
dons, 175 

Anatomy  of  the  now-born,  17 

Anchylostomata,     269;     anaemia,     269 

Anderson's  dusting  powder,  647 

Anencephalus,  21,  150 

Angina,   Vincent's,   210.  220 

Animal   amyloid,  93;  animal  gum.  93 

Ankyloblepharon,  156 

Anophthalmos,  l~>t> 

Antitoxin.  573;  effects  of,  575;  im- 
munizing dose,  57  1 

Antrum  of  Ilighmore,  48;  mastoid,  at 
birth.  20 

r.49 


650 


INDEX 


Anuria,  366;  enteroclysis  in,  367;  of 
new-born,  163,  172 

Anus,  fissure  of,  281;  prolapse  of,  280 

Aortic  insufficiency,  299;  lesions,  299; 
stenosis,  299 

Aphasia,  417;  amnesic,  438 

Aphonia,  hysterical,  406 

Aphthae,  207;  Bednar's,  208 

Apoplexy  of   adrenals,  490 

Appendicitis,  274;  leucocytosis  in, 
276;  recurrence  of,  278;  tubercu- 
losis, 278 

Aran  and  Duchenne  type,  475 

Arnold's  sterilizer,  117 

Arterial  tension  in  infancy,  61 

Arteries,  growth  of,  54;  umbilical,  32 

Arthritis,  acute,  521;  deformans,  523; 
in  rheumatism,  629;  syphilitic, 
521 

Articulation,  vocal,  72 

Artificial  feeding,  110,  114;  composi- 
tion of  food,  110;  difficulties  in, 
125;  egg  in,  128;  essentials  for, 
110;  rules  for,  125 

Asafetida,  milk  of,  648 

Ascaris  lumbricoides,  269;  treatment 
of,  271 

Ascites,  285 

Asperin,  647 

Asphyxia  neonatorum,  168;  treatment 
of,  169 

Aspiration  in  hydrocephalus,  152;  in 
pneumonia,  170 

Asthma,  335,  eosinophilia  in,  336 ;  gout 
in,  337;  rhachiticum,  402;  treat- 
ment of,  337;  urticaria  in,  337 

Astigmatism,  534 

Astringents,  646 

Ataxia,  cerebellar,  439,  473 ;  hereditary 
spinal,  472 

Atelectasis,  145;  acquired,  356;  con- 
genital, 171 ;  diagnosis  of,  357 ; 
symptoms  of,  357;  treatment  of, 
171,  358 

Atelomyelia,  153 

Athetosis,   68,  413 

Athrepsia,  182 

Atomization,  645 

Atomizer,  134 

Atresia   ani,   159;    of   auditory   canal, 


157 ;  of  mouth,  158 ;  of  oesophagus, 

159;    recti,    159;    urethral,    163; 

vaginal,  vulval,  163 
Atrophy,  infantile,  182 
Attention,  power  as  test  of  mentality, 

457 
Auditory  canal,  atresia  of,  157 
Auricles,  supernumerary,  157 
Automobility,   72 

B 

Babcock,  93,  113;  method  of  milk 
analysis,  101 

Babinski's  sign,  423,  475 

Baby  bag,  65;  foods,  125,  126,  130 

Bacillus,  chromogenic,  250;  coli  com- 
munis, 92;  Eberth's,  578;  Hiip- 
pe's,  92;  Klebs-Loeffler,  in  croup, 
322;  in  diphtheria,  568 

Backward  children,  457  to  459,  534 

Bacteria  of  faeces  in  infancy,  76;  in- 
testines, 67;  varieties  of,  67 

Bacterium  coli  commune,  67,  77;  lactis 
aerogenes,  67,  77,  93;  putrefac- 
tive, in  milk,  93 

Balanitis,  384 

Baner's  rule,  118 

Banti's    disease,    489 

Barber's  itch,   614 

Barley-water,  642;  analysis  of,  130 

Basedow's  disease,  496 

Baths,  82;  bran,  82,  639;  contraindi- 
cations, 82 ;  duration  of,  fre- 
quency of,  82;  in  childhood,  140; 
mustard,  638;  salt,  82;  shower, 
639,  sponge,  638;  temperature  of, 
time  of,  82;  tub,  638;  vapor,  639 

Bednar's  aphthae,  208 

Bed-sores  in  transverse  myelitis,  467; 
prevention  of,   634 

Behring,   593 

Bile  acids,  67;  bactericidal  power  of, 
67;  in  infancy,  73;  of  new-born, 
66 

Birth-marks,  163 

Birth-palsies,  448 

Bladder,  at  birth,  39 ;  capacity,  39,  40, 
59;  exstrophy,  162;  growth  of, 
58 ;  peritoneal  covering  of,  40,  58 ; 
location  of,  39,  40,  58 


ENDEX 


651 


Bleeders,  507 

Blepharitis,  simple,  524;  treatment, 
524;  ulcerative,  524 

Blepharospasm,  526 

Blood,  at  birth,  amount  and  character- 
istics of,  62;  circulation  of,  31, 
61;  diseases  of,  498  to  510.  In 
anaemia,  49S;  appendicitis,  27b' ; 
asthma,  336 ;  chlorosis,  500 ;  chol- 
era infantum,  528;  diphtheria, 
569 ;  Hodgkin's  disease,  4S6 ;  in- 
fluenza, 565;  leukaemia,  503; 
malaria,  583;  measles,  550;  men- 
ingitis, 427;  pernicious  anaemia, 
501,  503;  pertussis,  561;  pneu- 
monia, 342;  rhachitis,  190;  rheu- 
matism, 630;  scarlet  fever,  544; 
tuberculosis,  597;  typhoid  fever, 
580.  Peculiarities  of,  in  infancy, 
49S.  Supply  of,  adrenals,  38; 
brain,  63;  liver,  63;  lower  ex- 
tremities, 63;  skin,  68;  thyroid, 
33,  492 

Blood-vessels,    changes    in,    54 

Blue  baby,  170 

Bone-marrow,  18;  in  leukaemia,  506 

Bones,  composition  of,  at  birth,  18; 
diseases  of,  511;  ethmoid,  frontal, 
22;  inferior  maxillary,  32;  long 
bones  at  birth,  25;  occipital,  20; 
parietal,  22;  rhachitic,  192;  sphe- 
noid, 20;  supernumerary,  20; 
temporal,  20 ;  tuberculous,  508, 
511;   Wormian,   20 

Bothriocephalus,  269;  anaemia,  269 

Bottle  feeding,  technique  of,  124 

Bouche  de  tapir,  477 

Bowditch,   141 

Bowlegs  of  infancy,  135;  due  to  bulky 
diapers,  136 

Brain,  abscess  of,  441;  blood  supply, 
63;  cellular  multiplication,  59; 
coverings  and  vessels,  41 ;  develop- 
ment, 41;  growth,  59;  time 
of  most  rapid,  456;  causes  of 
arrest,  456.  Impairment  of,  causes, 
post-natal,  456 :  peculiarities,  size, 
weight,  41;  ratio  to  body  weight. 
59  ;  tuberculosis,  597.  Tumors.  436 ; 
symptoms,  437;  diagnosis,  440; 
treatment,  441 


Branchial  clefts,  22,  24;  fistulas,  158 

"Bread-tray  belly," 

Breast  milk,  changes  in,  during  lacta- 
tion, 94;  conditions  influencing 
secretion,  97;  Eats,  role  of,  91; 
means  for  regulating,  !»!);  mineral 
constituents,  93;  proteids  of,  90; 
sugar  of,  91 ;  variations  in,  97,  106 

Broadbent's  sign,  309 

Bromoform,  564 

Bronchial  glands,  34 

Bronchiectasis,  333;  diagnosis  and 
symptoms,    334 

Bronchioles,  52 

Bronchi,  relation  of,  52 

Bronchitis,  326 ;  absence  of  expectora- 
tion in,  328;  an  accompaniment 
of  infections,  327;  acute,  326; 
bacteria  in,  327;  capillary,  329, 
347;  chronic.  331;  croupous,  333; 
diagnosis  of,  329;  etiology,  327; 
fibrous,  333 ;  prognosis  of,  329 ; 
symptoms,  328 ;  treatment,  330 

Bronchopneumonia,  329,  347;  after 
measles,  552;  bacteria  in,  349; 
complications  in,  350;  diagnosis, 
351 ;  etiology,  34S ;  leeches  in, 
352 ;  sequelae,  351 ;  symptoms,  349 ; 
treatment,  352 

Broths,  beef,  chicken,  clam,  mutton, 
and  oyster,  643 

Budin,  129 

Buhl's  disease,  ISO 

Bulbar  paralysis,  439.  453;  pseudo, 
455 ;  symptoms  in  Friedreich's  dis- 
ease, 473;  in  multiple  sclerosis, 
475 

Bunge,  91 

Buttermilk,  115 


Cachexia,  splenic,  489 

Caecum,  in  early  life.  36 

Calcium.  127:  casein.  75,  92;  para- 
casein. 75;  chloride.  50S;  phos- 
phate in  breast  milk.  91 ;  salts  in 
milk,  129 

Calculi,  salivary,  204.  Vesical.  37^: 
urine  in.  379;  treatment  of, 
379 ;    X-ray   in    diagnosis.    379 


652 


INDEX 


Cahnuck  type  of  imbecility,  458 

Cancrmii  oris,  212 

Canker  sore  mouth,  207 

Capacity  for  attention,  143 

Capillary  bronchitis,  329 

Caput  obstipum,  157;  succedaneum, 
18,  149 

Carbohydrates,  93;  of  milk,  90,  91 

Cardiac  dulness,  area  of,  53,  300,  301; 
von  Starch's  type,  53 

Caries,   cervical,  512 

Carpopedal  spasm,  403 

Casein,  75,  92;  calcium,  74,  75,  92; 
hydrochloride,  75,  92;  in  cow's 
milk,  126,  128,  129;  lactate,  75, 
92 

Casts  in  early  infancy,  07, 

Catalepsy,  408 

Cataract,  534;  congenital,  156 

Catarrh,  acute  nasal,  311;  alveolar, 
329;  chronic  intestinal,  265;  gas- 
tric, 241;  suffocative,  329 

Centrifuge,  Babcock's,  102;  Leffmann 
and  Beam's,  103 

Cephalhematoma,  149 

Cephalic  cry,  423 

Cereal  gruels,  129,  256,  642 

Cerebellar  form  of  Friedreich's  dis- 
ease, 473 

Cerebral  croup,  402 

Cerebritis,  431 

Certified  milk,  124 

Chadwick,  143 

Chalazion,  525 

Chapin,  111,  113,  129;  dipper,  121; 
method  of  milk  modification,  121 

Charcot-Leyden  crystals,  333;  in 
asthma,  336 

Charcot-Marie-Tooth  type,  475,  476 

Cheadle's  essentials,  110 

Chemosis,  530 

Cheyne- Stokes  respiration,  424 

Chicago  milk  commission,  116 

Chicken-pox,  558 ;   diagnosis,   559 

Childhood,  classification  of,  42 ;  diet  in, 
139;  heart  in,  141;  physiology  and 
hygiene  of,  138 

Child*  labor,  144 

Chittenden,  113,  131 

Chlorosis,  500;  blood  in,  500;  symp- 
toms, 500;  treatment,  501 


Cholaemia,  178 

Cholera  infantum,  257;  blood  in,  258; 
mortality,  257;  pathology,  257; 
symptoms,  257;  treatment,  258 

Cholesteatoma,    540 

Choluria  in  enteritis,  250 

Chondritis,   511 

Chondrodystrophy  fcetalis,   164 

Chorea,  40S;  and  rheumatism,  408; 
electric,  409;  habit,  411;  Hunt- 
ington's, 409;  minor,  409;  treat- 
ment, 410 

Christopher,  141 

Chronic  adenitis,  485 

Chvostek's  sign,  401 

Chyle,   74 

Chyme,  73,  74 

Circulation  of  blood,  changes  at  birth, 
61;  obstruction  of,  during  in- 
fancy, 63 

Cirrhosis,  liver,  285;  etiology,  285; 
lung,  353 

Class,  541 

Clavicle  at  birth,  25 

Claw-hand,  475 

Cleft  palate,  158 

Cleido-cranial  dysostosis,  165 

Clitoris,  adherence  of  prepuce,  389 

Clothing,  evils  of,  65;  infant's,  80,  81; 
material,  65;  of  the  new-born,  65; 
requirements  of,  65 

Clubbed  fingers,  292 

Club-foot,  155 

Coagulability  of  milk,  128 

Cold  in  the  head,  311 

Cold  pack,  638 

Colica  mucosa,  265 

Colic,  due  to  uric  acid  crystals,  90, 
244;  intestinal,  244;  renal,  244; 
symptoms,  245;  treatment,  245 

Colomba,  156;  iridis,  156 

Colon,  characteristics  of  infant,  57; 
congenital  dilatation  of,  160 

Colostrum,  70,  108;  characteristics  of, 
94;  role  of,  86 

Compensation  in  heart  disease,  299 

Condensed  milk,  131 

Congenital  disease  of  heart,  289;  mal- 
formations, 149 

Conjunctiva,  burns  of,  532;  injuries 
of,  532 ;  wounds  of,  532 


INDEX 


653 


Conjunctivitis,  527;  acute  catarrhal, 
527;  etiology,  527;  treatment,  527. 
Chronic,  528;  croupous,  diphthe- 
ritic, 531;  follicular,  52S ;  gon- 
orrhoea!, 529;  kerato-phlyctenular, 
531;  purulent,  52!) ;  treatment,  530 

Connor's  table  for  milk  modification, 
123 

Constipation,  262;  in  childhood,  140; 
in  infancy,  137;  treatment,  261 

Constitutio  lymphatica,  480 

u  Consumption  of  the  bowels,"  599 

Contagious  diseases,  634,  care  of,  634 

Contractures,  in  myelitis,  467;  in  pro- 
gressive muscular  atrophy,  476 ;  in 
spinal  paralysis,  470 

Convolutions  of  brain,  at  birth,  41 

Convulsions,  394,  401 ;  diagnosis  in, 
395;  etiology,  394;  in  hydro- 
cephalus, 152 ;  prognosis,  396 ;  in 
rhachitis,  19S;  treatment,  396 

Coordination,  72;   development  of,  71 

Coprolalia,  416 

Cord,  in  Friedreich's  disease,  472; 
hemorrhage  in,  466 ;  malforma- 
tions of,  153 ;  pressure  symptoms, 
466 ;  spinal,  tumors  of,  154,  471 

Coryza,  311 

Couveuse,  146 

Cow-pox,  556 

Cow's  milk,  how  it  differs  from  human 
milk,  126;  intolerance  of,  126 

Coxitis,  514 

Cranial  sinuses,  thrombosis  of,  434 

Craniotabes,  rhachitis,  191 

Cream,  centrifugalized,  116,  124;  grav- 
ity, 116,  IIS;  percentage  of  fat 
in,  119;  separated,  IIS 

Cream  of  tartar  lemonade,  644 

Creamometer,  Holt's,  100;  Chevalier's, 
100 

Crede,  146 

Creeping  pen,   83 

Cretinism,  493 ;  acquired,  494 ;  en- 
demic, 495;  sporadic,  494;  symp- 
toms, 493 ;  treatment,  495 

Cricoid  cartilage,  52 

Cromby,  253 

Croup,  322 ;  diagnosis,  322 ;  membra- 
nous, 322 ;  symptoms,  322 ;  treat- 
ment, 323 ;  true,  322 


Cry,  in  infancy,  72;  of  new-born,  L68 

<  Jryptorchidism,  392 

Cupped  foot,  472 

Curds,  75;  effect  of  sodium  citrate  on, 
130;  curds  in  stools,  129,  L30 

Curschmann's  spirals,  333;  in  asthma, 
336 

Cutis  tensa  chronica,  621 

Cyanosis,  292;  infantum,   170 

Cyclic  albuminuria,  308;  vomiting,  238 

Cystic  tumors  of  cord,  154 

Cystitis,  381;  in  myelitis,  467;  symp- 
toms, treatment,  382 

Cysts,  dermoid,  156,  204;  of  kidney, 
371 ;  of  mouth,  204 

Czerniak,  224 

D 

Dactylitis,  syphilitic,  588;  tuberculous, 
51S;  diagnosis,  519 

Dairy,   hygienic   management    of,   110 

Dane,  134 

Deaf-mutism,  417 

Deafness  from  mumps,  567;  in  hered- 
itary syphilis,  590 

Decalcified  milk,  129 

Decaseinized  milk,   128 

Defects  of  bones,  congenital,  164;  of 
umbilicus,  160 

Deformities,  144 

Degeneration,  acute  fatty,  180 

Dementia  prascox,  465,  466 

Dentition,  205;  early,  205;  otalgia, 
205 ;  reflex  disorders,  419 ;  relation 
to  disease,  205;  retarded,  205; 
treatment  of  painful,  206 

Dermatosclerosis,  621 

Dermoid  cysts,  156,  204 ;  in  mouth,  204 

Development,  overstimulation  of,  83 

Dextrinized  gruels,  130 

Diabetes  insipidus,  627;  melitus,  624; 
heredity  in,  624;  prophylaxis,  626; 
treatment,  62.") 

Diapers,  66,  S3;  constrictions  from, 
136 

Diaphragm  at  birth.  34 

Diaphysis,  25 

Diarrhoea,  summer.  247;  tubular.  265 

Diastasis  of  recti  muscles.  160;  treat- 
ment of.  161 

Diazo  reaction,  579 


654 


INDEX 


Diet,  in  later  infancy,  137;  in  child- 
hood, 139 

Dietary,  642 

Digestion,  development,  132;  evolution 
of,  75;  in  infancy,  73,  75;  per- 
sonal equation  in,  93 

Digestive  system,  diseases  of,  201. 
Digestive  tract,  development  of, 
111;  length  of,  in  infants,  111; 
in  calves,  111;  malformations  of, 
158 

Digitalis,   302 

Dilatation,  acute,  of  left  ventricle,  303 ; 
of  colon,  160;  of  heart,  299;  of 
stomach,  160 

Dilated  ventricle,  143 

Diphtheria,  568;  albuminuria,  570;  an- 
gina, 570 ;  bacteriology,  568 ; 
blood,  569;  complications,  573; 
convalescence,  575;  diagnosis,  572; 
etiology,  568;  of  the  trachea,  326; 
nervous  tissue,  569;  paralysis, 
572;  pathology,  569;  prognosis, 
572;  sequelae,  573;  sine  mem- 
brana,  571 ;  symptoms,  569 ; 
treatment,  573;  types,  571 

Diplegia,  447;  in  transverse  myelitis, 
467 

Diploe,  46 

Diplomyelia,  153 

Diplopia,  534 

Dipper,  Chapin's,  121 

Dipsomania,  465 

Diseases,  of  blood,  498;  bones  and 
joints,  511;  digestive  system,  201; 
ear,  536;  eye,  524;  general,  624; 
genito-urinary  tract,  366;  glands, 
480;  glands,  blood,  bones  and 
joints,  480;  heart  and  pericar- 
dium, 289;  infectious  and  hemor- 
rhagic of  new-born,  176 ;  infec- 
tious specific,  541;  intestine,  244; 
lips,  201;  liver  and  pancreas,  283; 
mouth,  204;  nervous  system,  394; 
of  new-born,  166;  nutrition,  182; 
rectum  and  anus,  278 ;  respiratory 
tract,  311 ;  skin,  604 ;  stomach, 
237;  throat,  pharynx,  oesophagus, 
215;  tongue,  201 

Disinfecting  solutions,  645 


Disinfection,   634 

Dislocation  of  hip,  congenital,  155 

Disorders,    of    digestive    system,    201; 

of  nutrition,  182 
Disseminated  sclerosis,  474 
Distichiasis,  525 
Diverticulum,  Meckel's,  159 
DobelFs  solution,  646 
Drop  .foot,  479 ;  wrist,  479 
Drugs,  administration  of,  635 
Ductus  arteriosus,  30;  venosus,  31 
Duodenum,    at    birth,    35;    secretions 

of,  66 
Dura  mater,   at  birth,   41 
Dusting  powders,  647 
Dyspepsia,  acute,  246 
Dysentery,  amoebic,  261 

E 

Ear,  at  birth,  21;  diseases,  536;  inter- 
nal, 540;  malformations  of,  157; 
strain,  143 

Eberth's  bacillus,  578 

Ecchymosis,  508,  526,  532 

Echinococeus,  2S7 

Echolalia,  416 

Eclampsia  infantum,  394 

Ectopia  vesicas,  162 

Ectropion,  526 

Eczema,  606 ;  diagnosis  of,  608 ;  treat- 
ment, 60S 

Education,  141 

Egg,  albumin,  115,  128;  proteids,  128; 
water,  643;  yolk,  fat  in,  129 

Egotism,  464 

Elaboration  of  brain  cells,  60 

Elongatio  frenuli,  204 

Emboli  in  heart  disease,  296,  301 

Emotions  in  infancy,  72 

Emphysema,  pulmonary,  358;  subcu- 
taneous, 359 

Empyema,  363 ;  treatment  of,  365 

Emulsion   of  fats,   648 

Encephalitis,  431 

Encephalocele,  150 

Endocarditis,  acute,  295;  diagnosis, 
297;  lesions,  295;  symptoms,  295; 
treatment,  297.  Chronic,  298; 
diagnosis,  300;  lesions,  295;  prog- 
nosis, 301 ;  symptoms,  299 ;  treat- 


INDEX 


655 


ment,  302.  Infectious,  296;  in 
tonsillitis,  216;  malignant,  290; 
prenatal,  290;  rheumatism,  causes 
of,  298;  ulcerative,  296 

Enema,  641 

Enteralgia,  244;  in  pneumonia,  244 

Enteric  fever,  578 

Enteritis,  acute,  247;  classification, 
etiology,  248 ;  bacteria,  diet,  251 ; 
pseudomembranous,  252 

Enteroclysis,  641 ;  in  anuria,  367 

Enterocolitis,  252;  diet  in,  256;  folli- 
cular, membranous,  253;  prophy- 
laxis, 253;  pseudomeningitis  in, 
253;  reinfection,  254;  treatment, 
253 ;  ulcerative,  253 

Entropion,  525 

Enuresis,  390;  treatment,  391 

Enzymes,  of  milk,  93;  of  saliva,  74 

Eosinophilia,  269 

Epicanthus,  156 

Epiglottis,  direct  examination  of,  28 

Epilepsy,  463 ;  and  migraine,  420 ; 
diagnosis,  399;  focal,  398,  438;  in 
birth-palsies,  449;  Jacksonian, 
398,  438;  masked,  39S;  prognosis, 
399;  psychic,  39S;  treatment,  400 

Epinephritis,  382 

Epiphyses,  25 

Epiphysitis,  acute,  520,  522 

Epispadias,  163 

Epistaxis,   316 ;   treatment,   317 

Erb's  paralysis,  174 ;  sign,  401 ;  type, 
475 

Erotomania,   465 

Eruptions  from  antitoxin,  575 

Erysipelas,  179 

Erythema  simplex,  605 

Es'eherich,  76,  92,  547 

Ethmoidal  cells,  47 

Ethmoid  bone,   22 

Eustachian  tube,  24;  at  birth,  21,  22; 
growth,  47 

Eustachian  valve,  30 

Examination  of  children,  166;  of 
mouth,  168;  rectal.  168 

Exanthemata,  541;  differential  diag- 
nosis, table,  560 

Exencephalus,  150 

Exercise,  83 


Exomphalos,  congenital,  160 

Exophthalmos,  535 

Exstrophy  of  bladder,  162 

External  auditory  meatus,  46;  table  of 
Length,   16 

Extremities,  deformities  of,  L54 

Exlubation,  578 

Eye,  at  birth,  23;  diseases  of,  524;  in- 
juries of,  534;  malformations  of, 
155;  paralysis  of  muscles  of,  534; 
perforation  of,  534;  refraction 
of,  534 

Eye-grounds  in  amaurotic  idiocy,  4(>i>; 
eye-strain,  143 

F 

Face,  at  birth,  23 ;  growth  of,  47 

Facial  defects,  158 

Fades  myopathique,  477 

Facio-scapulo-humeral  atrophy,  475 

Faeces,  at  birth,  67 ;  bacteria,  76 ;  char- 
acteristics of,  73 ;  color  in  infancy, 
73;  composition  of,  73,  76;  fre- 
quency of,  73;  incontinence  of, 
261;  in  infancy,  67,  73;  odor,  73 

Farrington,  104 

Fat  absorption,  66;  determination  of, 
100;  methods  of  Babcoek,  Chev- 
alier, De  Laval,  Feser,  Holt,  Leff- 
mann  and  Beam,  Marchand,  Sox- 
hlet,  100;  relations  of,  to  specific 
gravity,  103 

Fatigue,  144;  period,  142 

Fatty  diarrhoea,  97;  liver,  2S6 

Favris,  616 

Feeble-mindedness,  455 

Feeding,  85,  89;  artificial,  114;  Ameri- 
can methods  of  artificial,  115 ;  ad- 
vantages of,  115;  failures  in,  115; 
danger  in,  116;  percentage.  114; 
points  to  be  observed,  132;  sodium 
citrate  in,  129:  whole  milk  in.  129. 
Bottle,  124.  In  pertussis.  564 ; 
premature  infants.  148;  nasal, 
641  :  rectal.  641  :  substitute.  86, 
106;  supplemental,  106;  tube  for 
premature  infants.  148;  tubes.  124 

Feet,  134:  care  of,  135 

Ferments.  67,  74:  amylolytic.  lipolytic, 
milk  curdling,  proteolytic.  67.  74 


656 


INDEX 


Feser's  lactoscope,  101 

Fetal  circulation,  31 

Fever,  72 

Fibrillary  twitehings,  473,  475,  476 

Fibrosis,  pulmonary,  353 

Fissures,  Rolando,  41,  59;  Sylvius,  41, 
59 

Fistula?,  branchial,  158;  facial,  159 

Flail  gait,  470 

Food,  artificial,  antiscorbutic  quality, 
111;  forms  of,  110;  origin, 
110;  quantity,  110;  sterility,  111. 
Essentials,  antiscorbutic  quality, 
111;  constituents  of,  110;  form 
of,  110;  quantity  of,  110;  sterility 
of,  111.  Eskay's,  131.  In  second 
year,  136.  Liebig's,  131.  Nat- 
ural, 85.  Nestle's,  131.  Dextrin- 
ized,  131.  Milk,  131.  Proprie- 
tary, 131;  modification  of,  132; 
temporary  use  of,  132.  Table  of, 
131.     Variety  not  desired,  112 

Foot  and  mouth  disease,  208.  Drop 
foot,  479 

Fontanelle,  closure  of,  46;  in  menin- 
gitis, 423 

Fontanelles,  19 

Foramen  caecum,   22,  47;   ovale,  30 

Forced  attitudes,  440 

Foreign  bodies  in  the  nose,  316;  in 
pharynx  and  trachea,  325 

Formulas  for  home  modification  of 
milk,  119 

Formulary,  645 

Fraenkel's  diplococcus,  33S 

Fragilitas  ossium,  200 

Freeman,  117 

Freeman's  pasteurizer,  116 

Friedreich's  disease,  472;  cerebellar 
form,  473;  sign,  309 

Frontal  bone,  22;  sinuses,  47,  48 

Fumigation,  634 

Functional  disease  of  heart,  293 ;  diag- 
nosis, treatment,  294 

Furunculosis,  61S 

G 

Galactagogue,  97 
Gangrene  of  lungs,  355 
Gargle,  646 


Gastric  gland,  secretion  of,  at  birth, 
66;  ulcer,  243 

Gastritis,  acute,  241;  chronic,  259; 
feeding  hi,  260;  treatment  of,  260 

Gastro-enteric  tract,  diseases  of,  237 

Gastro-intestinal  infection,  endoge- 
nous and  exogenous,  251 

Gastroptosis,   259 

Gavage,  641 

Gelatin,  ISO,  508 

Genito-urinary  organs,  diseases  of, 
366;  development  of,  38  to  41 

Gibbous  kyphosis,  512 

Gilbert,  141,  142 

Glands,  bronchial,  34;  buccal,  55,  66; 
cervical,  483;  diseases  of,  480; 
gastric,  66;  inguinal,  484;  labial, 
55,  66 ;  lachrymal,  68 ;  Meibomian, 
525 ;  mesenteric,  484 ;  of  new-born, 
66;  palpable,  483;  parotid,  66; 
post-pharyngeal,  55;  salivary,  66; 
sebaceous,  6S ;  sweat,  68 

Glossitis,  acute,  202 ;  desquamative,  202 

Glottis,  oedema,  216,  323;  treatment, 
324;  spasm  of,  189,  318,  320,  322 

Glycerite  of  iodine,  646 ;  of  tannin,  616 

Glycosuria  in  infancy,  73 

Goat's  milk,  127 

Goitre,  exophthalmic,  496;  simple 
kyperaainic,  497 

Gonorrhceal  conjunctivitis,  529;  sto- 
matitis, 213;  vulvo-vaginitis,  386 

Gout  in  asthma,  337 

Gowers,  457,  460 

Grand  mal,  397 

Graves's  disease,  496;  heredity,  497; 
treatment,  497 

Green  stools,  67,  73,  250 

Grocery  milk,  116 

Growing  pains,  629 

Growth  in  infancy,  rate  of,  142;  of 
arteries,  51 ;  of  brain,  59 ;  relative, 
of  head,  chest,  and  pelvis,  44;  re- 
tarded, 44;  table  of,  45 

Gruels,  barley,  130;  cereal,  115,  130; 
dextrinized,  130 

Gummata,  periosteal,  521 

Gums,  lancing,  206 

Gunhammer  position,  423 

Gurler's  table,  120 


INDEX 


657 


H 

Habit  chorea,  spasm,  526 
Haamatemesis,  spurious,  244 

Haematoma    of    sterno-mastoid,    157; 

Haematoniyelia,  466 

Hematuria,  197,  296,  367,  509 

Haemic  murmur,  504 

Haemoglobin,  at  birth,  62;  in  Hodg- 
kin's  disease,  4S6;  in  later  in- 
fancy, 63 

Haemoglobinuria,  367;  epidemic,  ISO 

Hemolysis  in  pernicious  anaemia,  501 

Haemophilia,  heredity  of,  507;  joints 
in,  SOS 

Hahner,  96 

Hallucinations,  463 

Harelip.  158 

Harrington,   113 

Hart,  92,  113 

Headache,  419,  420,  580,  593 ;  occipital, 
439 

Head-nodding,  412 

Hearing,  at  birth,  69;  development 
of,^  71 

Heart,  apex,  location  of,  54;  at  birth, 
weight,  structure,  position,  29 ; 
changes  after  birth,  30;  chronic 
valvular  disease,  29S;  conscious- 
ness, 293;  defects  in  development, 
32,  33;  development  of,  32,  52; 
diseases  of,  2S9;  embryonic,  32; 
functional  disease,  293;  in  child- 
hood, 141;  in  diphtheria.  572;  in 
influenza,  564 ;  malformations, 
290;  position,  53;  rhythm,  61; 
symptoms,  291 ;  treatment,  292 ; 
valvular  defects,  299 

Heat  prostration,  432 

Hebephrenia,  465 

Hemianaesthesia,  407 

Hemiplegia,  in  endocarditis,  296 ; 
spastic,  447 

Hemorrhages,  adrenalin  in.  ISO;  cal- 
cium chloride  in,  ISO;  gelatin  in, 
ISO;  in  scurvy,  197;  intracranial, 
456;  of  the  new-born,  ISO;  sub- 
aponeurotic, 149;  sub-dural.  41; 
sub-pial,  41:  umbilical.  17S;  vagi- 
nal. 181 

Hemorrhoids,  2S2 


Henoch's  purpura,  509 
Hepatitis,  suppurative,  284 

Hereditary     spastic     paralysis,      V73j 

spinal     ataxia.     472;     cerebellar 

form.  47:! 
Heredity,  82;  in  imbecility,  455 
Hernia    cerebri,    150;    aspiration    in, 

151  :    cause-    of,    I'll 

Hernia,  diaphragmatic,  162;  inguinal, 
treatment  of,  161;  of  brain,  20, 
150;  of  umbilicus,  congenital,  160; 
of  umbilicus  in  cretinism,  493 

Herpes,  613;  treatment  of,  614 

Hip  disease,  514,  515,  516 

Hipp  us,  423 

Hips,  congenital  dislocation  of,  155 

Hirseh,  460 

Hives,  611 

Hodgkin's   disease,  485;   etiology,   486 

Holt,  113;  creamometer,  100;  home 
modification  of  milk,  118 

Hordeolum,  525 

Hot  pack,  637 

Hiippe,    92 

Hydatids   of  the   liver,   2S7 

Hydrencephalocele,  150 

Hydrocele,  392;  congenital,  infantile, 
392 ;  encjTsted,  in  girls,  393 ;  treat- 
ment of,  393 

Hydrocephalus,  426 ;  acute,  443,  446 
acquired,  446;  congenital.  151 
446 ;  diagnosis  of,  446 ;  lesions 
445;  lumbar  puncture  in.  152 
spontaneous  evacuation,  152 
symptoms,  444 

Hydrochloric  acid.  66,  73.  75;  in  infant 
stomach,  74,  75.  76 

Hydrochloride  of  casein,  92 

Hydromyelia,  472 

Hydronephrosis,  3S3 

Hydrops  cerebri.  443 

Hydrotherapy.  637:  in  typhoid.  581 

Hygiene,  importance  of,  82;  of  child- 
'  hood,  138;  of  first  year.  7-.  85;  of 
infancy.  77:  of  lactation,  96;  of 
later  infancy.  133;  of  the  prema- 
ture infant.  145:  of  the  school- 
room, 143;  of  the  sick-room.  633 

Hymen,  imperforate.  163 

Hyperacusis,  461 


42 


658 


IXDEX 


Hyperopia,  534 

Hypertrophy,  of  the  heart,  299;  ton- 
sils, 219;  deafness,  220;  treatment, 
220 

Hypochondriasis,  464 

Hypodemioelysis,  256 

Hypospadias,  163 

Hypostasis,  pulmonary,  355 

Hysteria,  105;  aphonia  in,  106;  diag- 
nosis of,  107;  heredity,  106;  torti- 
collis in,  106;  treatment  of,  107 


Ichthyosis,   620 

Icterus   neonatorum,    176;    grave,    177 

Idiocy,    155;    amaurotic    family,   159; 

lesions  in  amaurotic  family,  161. 

Birth    accidents    as    causes,    156; 

congenital,     156;     etiology,     156; 

Mongolian,  158;  prophylaxis,  159; 

types,  157 
Idiots,  brain  pathology  in,  157 
Imbecility,     155;     associated     defects, 

157;  training  in,  159 
Imperative     acts,     165;     conceptions, 

165;  movements,  112 
Imperial  granum,  131 
Impetigo  contagiosa,  612 
Inanition  fever,  171 
Incompetency,  valvular,  299 
Incontinence,  of  faeces,  261;  of  urine, 

390 
Incubator,    116 
Indigestion,  acute,  216;  intestinal,  265; 

vomiting  in,  237 
Infancy,   periods  of,   42 
Infantilism,  590 
Infant,  wants  of,  78 
Infectious  diseases,  511 
Inferior  maxilla,  23,  47 
Influenza,  564 ;  blood  in,  complications, 
diagnosis,      symptoms,      sequelae, 
types  of,  565 ;  treatment,  566 
Inguinal  canal,  development  of,  59 
Inhalations,  in  asthma,  337;  in  laryn- 
gitis, 320;  in  pertussis,  564 
Insanity,  463 

Insolation,   432;   blood  in,   433;    diag- 
nosis, sequelae,  433 ;  treatment,  434 
Inspection,  value  of  examination,  166 


Inspiration  pneumonia,  170 

Insular  sclerosis,  174 

Intention  tremor,  474 

Intermittent  fever,  582 

Intestinal    occlusion,    159;    parasites, 

268 
Intestines,  at  birth,  35,  56;  length  of, 

36;  pecularities  of,  35;  aberrant, 

56;  bacteria  of,  67;  development 

of,    56.     Small,    growth    of,    57; 

measurements,  56 
Intubation,  576 ;  feeding  after,  578 
Intussusception,  272 ;  treatment  of,  274 
Iritis,  533 
Iron,  in  breast  milk,  91,  92;  infant's 

liver,  92 
Irrigation,    colonic,    611;    nasal,    639; 

stomach,  610;  vaginal,  611 
Itch,  617 

J 

Jacksonian  epilepsy,  398,  438 

Jacobi,  129 

Jacubowisch,  66 

Jaundice,   of   new-born,   176;   pseudo, 

177 
Joints,   diseases   of,  511;  tuberculous, 

511 
Jugulars,  pulsation  of,  301 
Junket,  75,  644;  egg,  644 

K 

Kaposi's  disease,  622 

Katatonia,  465 

Kennicutt,  93 

Kephir  milk,  128 

Keratitis,  interstitial,  532 

Kernig's   sign,    124,   580 

Kidneys,  amyloid  degeneration,  378 
at  birth,  38;  congenital  anomalies 
369;  cystic  degeneration,  369 
diseases  of,  366;  displacement  of 
370 ;  growth  of,  58 ;  lobulation,  58 
malformations,  369 ;  movable,  370 
peculiarities  of,  38;  position  of, 
38,  58 

Kindergarten,  110 

Kirke,  73 

Klebs-Loeffler  bacillus,   322,   568 

Kleptomania,  465 


[NDEX 


659 


Knee-joint  diseases,  517 
Koch,  593 
Kbnig,  127 
Koplik's  sign,  550 
Koumiss,  128 
Krohn's  diagram,  142 
Kyphosis,  512 


Labyrinthitis,  540 
Lactalbumin,  92 

Lactate  of  casein,  92 

Lactates;  93 

Lactation,  S5;  automatic  adjustment 
of,  96;  coitus,  effects  of,  98;  con- 
ception, effects  of,  98;  defective, 
97;  diet  in,  97;  disturbances, 
causes  of,  97;  failures  in,  97; 
hygiene  of,  96 ;  menstruation, 
effect  of,  98;  mental  condition, 
effects  of,  97,  98;  perversion, 
effect  on  child,  98 

Lactic  acid,  66,  92 

Lactoglobulin,   92 

Lactoscope,  101 ;  Feser's,  101 

Lactose,  92,  93 

Ladd's  table,  119 

La  grippe,  564 

Landouzy-Dejerine  type,  475 

Landry's  paralysis,  473 

Lanugo,  17,  68 

Laryngismus  stridulus,  318,  402;  re- 
lation to  rhachitis,  403 

Laryngitis,  acute,  318;  bacteria,  322; 
catarrhal,  318;  chronic,  320; 
pseudo-membranous,  322 ;  symp- 
toms, 319;  syphilitic,  321;  treat- 
ment, 320;  tuberculosis,  321 

Laryngospasm,  31S,   402 

Larynx,  at  birth,  27;  direct  inspection 
of,  28;  foreign  bodies  in,  325; 
position  of,  at  birth,  28;  tumors 
of.  324 

Lnssar's  paste.   648 

Laure,  96 

Lavage,  640 

Lecithin.  127;  in  amaurotic  family 
idiocy.  460 

Leeches.  293.  352:  in  pneumonia.  347, 
352 


Leeds,  113,  131 

Leffmann,  l.'Jl ;  and  Beam,  113;  Leff- 
inanii  and  Beam  method,  102 

Length,  at  birth,  17;  growth  in,  44 

Leptomeningitis,  424 

Lesage,  250 

Leucocytosis  at   birth,  02 

Leucopenia,  552;  in  malaria,  584;  in 
typhoid,  580 

Leukaemia,  503;  blood  in.  503;  diag- 
nosis, 506 ;  etiology,  504 ;  lym- 
phocytic, 505;  symptoms,  504; 
treatment,  500;  types,  505 

Lichen  tropicus,  610 

Lids,  affections  of,  524;  burns.  526; 
injuries,  526 

Lime,  91 

Lime  water,  115,  117.  124,  644 

Lingua  geographica,  202 

Lips,  diseases  of,  201 

Liquor  calcis,  115,  117,  124,  644 

Little's  disease,  474 

Liver,  abscess  of,  284 ;  acute  infectious* 
284;  acute  yellow  atrophy,  286; 
amyloid  degeneration  of,  287; 
blood  supply  of,  63;  boundaries 
of,  88;  congestion,  283;  ch-rhosis, 
285;  development  of,  36,  37;  dis- 
eases of,  283;  enlarged  in  icterus, 
178;  enlargement  of,  37:  fatty, 
286;  growth  of,  57;  hydatids,  287; 
iron  in  infant's,  92;  location  at 
birth,  37;  tumors,  287;  weight  of, 
at  birth,  37 

Locomotor  ataxia,  474 

Long  bones,  centres  of  ossification.  26; 
development  of.  25;  medullary 
canal,  26;  periosteum  of.  25 

Lumbar  puncture,  428,  636;  in  hydro- 
cephalus. 152 

Lumbricoides  in  larynx.  325 

Lung,  abscess,  355;  alveoli.  29,  52; 
anatomical  peculiarities.  327.  At 
birth.  28;  position  of.  29;  struc- 
ture of.  29;  weight  of.  29.  Blood- 
vessels, 52:  cirrhosis  of.  353;  col- 
lapse of.  356;  development  of.  •"]  ; 
gangrene,  355 :  physiological  con- 
gestion of,  327 

Luscbka's  tonsil.   224.   225 


660 


INDEX 


Lymphadenitis,  482;  in  Hodgkin's  dis- 
ease, 486 

Lymphadenoma,  485;  of  tongue,  202; 
splenic,  489 

Lymphaemia,  489 

Lymphangioma  of  tongue,  202 

Lymphatic  anaemia,  485 

Lymphatism,  319,  480;  and  tuberculo- 
sis, 593;  treatment,  482;  types  of, 
480 

Lymphocytosis,  487;  at  birth,  62;  in 
pertussis,  561 

Lymphoid  corpuscles,  66;  ring,  228; 
tissue  of  stomach,  55 


Macewen's  sign,  423 

Macrocheilia,  201 

Microglossia,  201 

Microstoma,  158 

Macula    lutea    in     amaurotic     family 

idiocy,  460 
Malaria,   582;    blood,    583;    diagnosis, 

etiology,     583;     leucopenia,    584; 

prophylaxis,  585;  symptoms,  583; 

treatment,  584 
Malformations,     congenital,     149;     of 

digestive  tract,  158;  of  ear,  157; 

of  extremities,  154;  of  eye,  155; 

of  heart,  290;  of  spinal  cord,  153 
Mallory,  541 
Malted  milk,  131 

Mammary  glands,  at  birth,  41;  evolu- 
tion of,  85 
Mania,  463 

Maransis,  184;  treatment,  184 
Marasmus,  182;  diagnosis,  184;  oedema 

in,   183;   pseudomeningitis,   183 
Marchand's  tube,  101 
Massage,  83,  636 
Mastication,  136,  176 
Mastitis  neonatorum,  176 
Mastoid  cells,  20;  process,  46 
Mastoiditis,    539;    complications,   539; 

sequels,  539 
Masturbation,  417 
Materna,  121 
Matzoon,  128 

Maxillary,  inferior,  at  birth,  23 
McCollom's  white  line,  546 


Measles,  549;  artificial,  549;  atypical, 
551;  black,  551;  blood  in,  552; 
character  of  eruption,  551;  com- 
plications, 551 ;  conjunctivitis,  550 ; 
diagnosis,  552.  German,  554; 
diagnosis,  554;  symptoms,  554. 
Hemorrhagic,  551;  mucous  mem- 
branes, 550;  prognosis,  552;  quar- 
antine, 553;  sequelae,  552;  symp- 
toms, 550;  treatment,  553 

Meat  juice,  raw,  644;  proteids,  115; 
raw,  643 

Meatus,  external  auditory,  20,  21 

Meckel's  diverticulum,  159 

Meconium,  67 

Medullary  substance,  60 

Meigs,  113 

Melsena  neonatorum,  181 

Melancholia,  413 

Membrana  tympani,  21 

Meningitis,  421;  basilar,  425;  bacteria 
in,  422;  blood  in,  427.  Cerebro- 
spinal, 426;  abortive,  426;  and 
pneumonia,  426;  fulminans,  425. 
Diagnosis,  427;  etiology,  422; 
examination  of  ears  in,  431;  in 
endocarditis,  297;  infantile,  non- 
tuberculous>  basilar,  430;  lumbar 
puncture,  431,  427.  Posterior 
basic,  430;  prognosis,  431;  symp- 
toms, prophylaxis,  430;  results  of, 
456;  secondary  to  infections,  421. 
Simple  basic,  430 ;  susceptibility  in 
infancy,  422;  syphilis  in,  431; 
symptoms  of,  423 ;  treatment,  429 ; 
tuberculous,  425 

Meningocele,  150;  spinalis,  154 

Meningomyelocele,  154 

Mental  dulness,  143' 

Meyer,  224 

Microcephalus,  152 

Microphthalmias,    156 

Micturition  at  birth,  68;  frequency  of, 
68;  in  infancy,  68 

Migraine,  420 ;  treatment,  urine,  421 

Miliaria,  610 

Milk,  acidity  of,  94;  alkali  in,  117; 
analysis,  100,  107;  microscope  in 
analysis,  104;  bacteria,  in,  116; 
boiled,    117;    breast,    90;    carbo- 


INDEX 


66] 


hydrates,  91 ;  certified,  124 ;  coagu- 
lability of,  129;  colostrum,  194; 
comparative  analysis  of  goat, 
ewe,  ass,  and  mare,  1-7;  com- 
parative analysis  of  bovine  and 
human,  113;  condensed,  131; 
constituents  of,  90;  cow's,  curds 
of,  75;  "crusts,"  G05;  curdling 
ferments,  67;  decalcified,  129;  de- 
caseinized,  12S;  decomposition  of, 
110;  dilution,  129;  enzymes  of 
human,  93;  fat  free,  1:24;  fats,  91; 
home  modification,  11(3,  118;  rules 
for  h.  m.,  118;  utensils  for  h.  m., 
124;  care  of  utensils,  124. 
Human,  effects  of  dry  diet  upon, 
96;  mental  conditions  influencing, 
97 ;  production  of,  95 ;  quantity  at 
different  periods,  96;  laboratories, 
114,  115;  lime  salts,  129;  nuclein 
in,  92,  126;  of  mammals,  112; 
paranuclein,  126 ;  peptonized,  127 ; 
phenolphthalein  test,  94;  phos- 
phorus. 02,  127;  predigestion  of, 
127;  production,  85;  proteids  of, 
90;  raw,  117;  reaction,  94;  salts, 
91;  secretion,  agents  influencing 
quantity,  97;  excess  of  fats  in 
secretion,  97;  regulation  of  secre- 
tion, 99;  specific  gravity,  90,  94; 
sugar,  91 ;  fermentation  of  sugar 
in,  77;  supply,  116;  synthesis, 
110;  table  of  mineral  constituents, 
93 ;  total  solids,  determination  of, 
104;  Rules  of  Farrington  and 
Woll,  104 

MUrine,  131 

Minnesota  daily  report,  131 

Mitral  insufficiency,  lesions,  stenosis, 
299 

Mixed  fats,  648;  infection  in  diph- 
theria, 569 

Moccasins,  135 

Modification  of  milk,  118;  Chapin's 
method,  121;  Connor's  table.  123; 
Gurler's  table,  120;  Ladd's  tables 
for,  119 

Mongolism  (Mongolian  idiocy),  458; 
degrees  in,  458;  obesity,  skin  in, 
tongue  in,  458 


Monne-Marie's  disease,  473 

Monophobia,  465 

Monoplegia,  449 

Morbilli,  549;  miliaria,  551 

Morbus  coeruleus,   170;  coxarius,  514; 

maculosus  Werlhofii,  509 
Morphine,  in  diphtheria,  574 
Mortality  of  infants,  causes  of,  108 
Moser's  serum,  547 
Motor  oculi  nerve  in  infancy,  71 
Mouth  breathing,   226;   care   of,   133; 

of  embryo,  22 ;  washes,  646 
Movements,  imperative,  412 
Mucocolitis,  265 
Mucous    disease,    265;    dilatation    of 

stomach  and  colon,  266;  etiology, 

266;  treatment,  267 
Muguet,  209 
Multiple  neuritis,  478;  etiology,  478; 

symptoms,  479 
Multiple   sclerosis,   474 
Mumps,  567 
Murmur,  301 ;  apical,  216 ;  haemic,  504 ; 

systolic,  502 
Muscles,  voluntary,  development  of,  71 
Muscular   atrophy   with  pseudohyper- 
trophy,   476;     dystrophies,     477; 

heredity,  477 ;  pseudohypertrophy, 

475 
Mutism  due  to  labyrinthitis,  540 
Myelitis,    cystitis    in,    467;     diplegia, 

symptoms,    467;    transverse,   466; 
Myelocytes,  505 
Myelosyringosis,  471 
Myocarditis,  303 ;    lesions,    symptoms, 

304;  treatment,  305 
Myopia,  534 
Myosthenia  gravis,  455 
Myotonia,  68 ;  congenita,  404 
Mysophobia,  464 
Myxoneurosis  coli,  265 

N 
Naevi,  163 
Nails,  at  birth,  17 
Xasal    diphtheria.    571 :    feeding.    641 : 

irrigation,    639;    irrigator,    134; 

septum,  47 
Nasopalatine  canal,  23 
Nasopharynx,  24.  48;  care  of.  133 


662 


INDEX 


Natural  feeding,  85 

Neck,   at   birth,   24;   hydrocele,   158 

Needs  of  the  inf  ant,  70 

Nephritis,  acute,  372;  chronic,  376; 
diagnosis,  374;  frequency,  376; 
in  pertussis,  563;  oedema  in,  373; 
pulse  in,   373;  treatment,  374 

Nerve  degeneration  in  diphtheria,  569 

Nerves,  anastomosis  of,  175;  peri- 
pheral sheaths  of,  60 

Nervous  system,  at  birth,  68;  diseases 
of,  394;  growth  in,  59;  in  amau- 
rotic family  idiocy,  461;  medul- 
lation,  60;  tracts  of,  71 

Nettle-rash,  611 

Neuralgia  enterica,  244 

Neuritis,  multiple,  478;  obstetric,  479; 
post-diphtheritic,  478 ;  treatment 
of  post-diphtheritic,  479 

Neutrophiles  in  Hodgkin's  disease,  487 

New-born,  anatomy  of,  17;  anuria, 
172;  care  of,  69;  cord  of,  69;  dis- 
eases of,  166;  eyes  of,  69;  infec- 
tious and  hemorrhagic  diseases  of, 
116;  infant,  needs  of,  70 

Night-terrors,  414,  415 

Noma  of  face,  212 

Normoblasts  at  birth,  62 

Nose,  at  birth,  23 

Nose-bleed,  316 

Notch  of  Rivinus,  21,  46 

Nourishment,  85 

Nucleon,  92 

Nursery,  79 

Nursing,  bottle,  124;  infant's  adapta- 
tion for,  85;  instinct  not  a  suffi- 
cient guide,  86;  mother's  adapta- 
tion for,  86 

Nutrient  enemata,  255 

Nutrition,  disorders  of,  182 

Nystagmus,  412,  535 

0 

Obstacles  to  application  of  hygiene,  77 
Obstetrical   paralysis,   174;    diagnosis, 

174 
Occiput,  flat  in  Mongolism,  4S5 
Occlusion,    intestinal,     159;     common 
site  of,  159;  of  bile-duct,  congeni- 
tal, 177 


OEdema,  623;  in  nephritis,  373;  of 
glottis,  216,  323 

Oesophagitis,  233 

OEsophagus,  at  birth,  35;  bifurcation, 
159;  constrictions,  35;  diseases  of, 
233;  fistula?  of,  159,  233;  foreign 
bodies  in,  233;  neurosis  of,  234; 
occlusion  of,  158;  spasm  of,  234; 
stricture,  233 

Oligsemia  sicca,  258 

Oliguria,  366 

Omphalitis,  179 

Ophthalmia.     See  Conjunctivitis 

Opisthotonos,  of  infancy,  cervical, 
430 

Oppenheim,  461 

Optic  atrophy  in  multiple  sclerosis, 
475 

Ossification,  at  birth,  18;  of  long 
bones,  25 

Osteitis,  511 

Osteochondritis,  511 

Osteogenesis  imperfecta,  164 

Osteomalacia,  199;  lime  salts,  paucity 
of,  199 

Osteomyelitis,  511 ;  acute,  522 ;  chronic, 
518 

Osteoperiostitis,  521 

Osteopsathyrosis,  200 

Otitis  interna,  540;  etiology,  540;  re- 
lation to  diabetes,  syphilis,  and 
chronic  nephritis,  540 

Otitis  media,  536,  bacteria,  537;  diag- 
nosis, 537;  etiology,  importance 
of,  536;  prophylaxis,  538;  sequel 
of  scarlatina,  537;  of  pneumonia, 
537;  simulating  meningitis,  538; 
treatment,  538 

Outing,  83 

Ova,  number  at  birth,  40 

Ovaries,  at  birth,  development,  40 

Overwork,  144 

Oxyuris  vermicularis,  269;  treatment, 
270 


Packs,  cold,  638 ;  hot,  637 

Palate    bones,    23;    cleft,    158;    high 

arched,  226 
Palsy,    infantile    cerebral,    447,    452; 


INDEX 


663 


contractures,  451;  diagnosis,  453; 
etiology,  450;  history,  451;  le- 
sions of  cord  in,  44S;  orthopaedic 
surgery  in,  453;  postnatal,  450; 
symptoms,  449 

Paludism,  582 

Pancreas  at  birth,  37 

Pancreatic  secretion,  73,  74;  ferments 
of,  67 

Pancreatitis,  syphilitic,  288;  tubercu- 
lous, 288 

Panphobia,  465 

Paracasein,  75,  76,  92 

Paralysis,  cerebrospinal,  473;  bulbar, 
439;  crossed,  439;  Erb's,  174; 
forms  of,  469;  hereditary  spastic, 
473 ;  labio-glosso-laryngeal,  439, 
453;  Landry's,  473;  natal,  448; 
obstetric,  174;  peripheral,  174; 
post-diphtheritie,  572 ;  progres- 
sive bulbar,  453;  pseudohyper- 
trophic, 476;  spinal,  468 

Paranephritis,  382 

Paranoia,  465 

Parapeptone,  73 

Paraplegia,  447;  following  infectious 
diseases,  466 

Parathyroid,  34,  492 

Parasites,  intestinal,  268;  in  ansemia, 
501 

Pai'etic  dementia,  462;  in  hereditary 
syphilis,  462 

Parietal   bone,   22 

Parotid  gland,  secretion  of  at  birth,  66 

Parotitis,  epidemic,  567 

Pasteurization,    117 

Pathophobia,  464 

Patulous  ventricular  septum,  32 

Pavor  diurnus,  414;  nocturnus,  414 

Pedatrophy,  182 

Pediculosis,    618 

Poliosis    rheumatica,    509 

Pemphigus  neonatorum,  178;  non- 
syphilitic,  peri-umbilical,  syphi- 
litic, 178 

Pepsin,  73,  75 

Peptogenic  milk  powder,  131 

Peptonization  of  milk,  127 

Percentage   feeding,   114 

Peribronchitis,  347,  353 


Pericarditis,  acute,  .':<).".;  adhesions  in, 
306 ;  aspiration  in,  300;  diaf 
in,  307 ;  I  real  ment,  307.  <  Ihronie, 
309;  sudden  death  in,  310.  Effu- 
sion in,  305 ;  exudate  in,  miliary 
tubercles  in.  symptoms,  306 

Pericardium,  adherent,  309;  at  birth,  1!' 

Periostitis,  518 

Perleche,  201 

Pedes  de  Laennee,  336 

Pernicious  anaemia,  501,  502;  blood 
in,  501;  diagnosis,  503;  heart,  502; 
symptoms,  502;  treatment,  503; 
urine  in,  502 

Perspiration,  72 

Pertussis,  561,  and  measles,  552;  blood 
in,  561;  complications,  563;  diag- 
nosis, 563;  feeding  in,  564;  hem- 
orrhages in,  562;  inhalations  in, 
564;  sequels,  563;  treatment,  563 

Petit  mal,  397 

Petrosal  bone,  20 

Petrosquamous    suture,    21,   46 

Pfeifer's  bacillus,  564 

Phalanges,  tuberculous,  518 

Pharyngitis,  acute,  222;  chronic,  224; 
rheumatic,  223 ;  syphilitic,  224 

Pharynx,  at  birth,  24;  diseases  of,  215 

Phimosis,  388;  effects  of,  389 

Phlyctamulae,  531 

Phospho-carnic  acid,  92 

Phosphorus  in  breast  milk,  92 

Phthisis,  fibroid,  353 

Physiology,  of  childhood,  138;  of  first 
year,  71 

Pityriasis  lingua?,  202 

Plaeques  pterygoidiennes,  208 

Plasmodia,  582 

Pleurisy,  359 

Pleuritis,  359;  aspiration,  362;  diag- 
nosis, 363;  operation  for  effusion, 
365;  pathologic  anatomy.  360; 
prognosis,  303 ;  rheumatic.  360 ; 
symptoms,  361 ;  traumatic,  360 ; 
treatment.    364 

Pleuropneumonia,  360;  pneumococcus 
in,  360 

Pneumococcus,  338 

Pneumonia,  338;  abdominal,  343; 
abortive,     342;     aspiration,     170; 


664 


INDEX 


atypical,  343;  bacteria,  338;  blood 
in,  342;  capillary,  347;  catarrhal, 
347;  central,  342;  cerebral,  343; 
complications,  343;  cough  in,  340; 
crisis,  340;  croupous,  338;  diag- 
nosis, 354;  fibrous,  338;  hypo- 
static, 184,  355;  inspiration,  170; 
interstitial,  353;  lobar,  338;  lob- 
ular, 347;  massive,  343;  of  short 
duration,  342;  pathologic  anat- 
omy, 338,  353;  Pfeiffer's  bacillus 
in,  343;  prognosis  of,  344;  pro- 
longed, 343;  pseudocrisis,  340; 
pulse,  341;  recurrent,  342;  sim- 
ulating appendicitis,  377;  symp- 
toms, 339,  353;  treatment,  345, 
354;  urine  in,  342 

Pneumonitis,  338 

Polioencephalitis,  acute,  432;  inferior, 
superior,  432 

Poliomyelitis,  acute  anterior,  468;  de- 
formities in,  470;  diagnosis,  470; 
etiology,  468;  muscles  involved, 
469;  pathology,  468;  prognosis, 
470 ;  stages,  469 ;  treatment,  470 

Polyarthritis,   chronic,   519 

Polypi,  nasal,  316;  rectal,  281 

Pomum  Adami,  52 

Porencephaly,  432 

Porter,  141 

Posthitis,  384 

Potassium  salts  in  breast  milk,  91 

Pott's   disease,   511 

Poynton,  129 

Precocity,  84 

Predigestion  of  milk,  127;  pernicious 
effects  of,  127 

Premature  infant,  feeding  of,  148 

Prematurity,  145 

Prepuce,  adherent,  40,  388 ;  at  birth,  40 

"  Prickly  heat,"  610 

Proctitis,  278;  prophylaxis,  280 

Progressive  muscular  atrophy,  475 

Prolapse   of   rectum,   280 

Propeptones,  73 

Proprietary  foods,  131 

Prostate  gland,  at  birth,  40 

Protection,  78 

Proteids,  in  artificial  feeding,  propor- 
tion to  fats,  115;  in  eggs,  128;  in 


whey,  92,  128 ;  of  breast  milk,  93 ; 
of  milk,  90,  91;  reduction  of  ex- 
cessive, 98 ;  soluble,  128 ;  split,  119, 
121 

Pseudo-ankylosis,   507 

Pseudodiphtheria,  576;  bacilli,  572, 
576 

Pseudoleukaernia,  485 ;  of  infancy,  506 ; 
splenic,  489 

Pseudomembrane  in  measles,  551;  in 
scarlatina,  545;  of  trachea,  326 

Pseudomeningitis   in   atrophy,   183 

Pseudoparalysis,  in  rhachitis,  191; 
syphilitic,  520,  589 

Psoas  abscess,  512 

Psoriasis,  619 

Psychopathies,  463;  prophylaxis,  465; 
treatment,  465 

Ptosis,  526;  congenital,  156 

Pubescence,  142,  466 

Pulmonary  circulation  at  birth,  61; 
hypostasis,  189,  355;  tuberculosis, 
594 

Pulse,  72;  in  second  year,  136;  rate 
affected  by  position,  61;  rate  at 
birth,  in  later  infancy,  61 ;  "  water 
hammer,"  301 

Pulse-respiration  rate,  327;  ratio,  136 

Puncture,  exploratory,   309 

Pupil,  paradoxical,  423 

Purpura,  508;  diagnosis,  510;  from 
drugs,  509;  fulminans,  509;  Hen- 
och's, simplex,  509;  treatment,. 
510;  urticans,  509    • 

Pyelitis,  380;  etiology,  380 

Pyelonephritis,  380 

Pyloric  stenosis,   congenital,   159,   240' 

Pyonephrosis,  380 

Pyrexia,  in  infancy,  72 

Pyromania,  465 


Quinine,  in  pertussis,  564 

Quinsy,  216;  apical  murmur  in,  216 


R 

Ranula,  204 
Raspberry  tongue,  544 
Reaction  of  human  milk,  94 


[NDEX 


Rectum,  at  birth,  .'!<>;  growth  of,  57; 
malformations  of,  L59;  peculiar- 
ities in  childhood,  •'!<>;  prolapse, 
36,  280;  ulceration,  278 

Reflexes,  418;  at  birth,  68,69 

Beilly,   Health   Commissioner,   02-1 

Relative  proportions  of  new-born,  18 

Rennet,  73,  75,  92 

Rennin,  92,  128 

Respiration,  63,  72;  causes  of  impair- 
ment of,  63;  development  of,  63; 
in  second  year,  13S;  in  young  in- 
fants, 63 ;  rate  of,  72 ;  ratio  to 
pulse,  64,  327;  types  of,  64,  72 

Respiratory  tract,  diseases  of,  311 

"  Rests,"  39 

Retardation  in  development,  292;  in 
growth,  44 

Retention  of  urine,  366 

Retro-oesophageal  abscess,  235 

Retropharyngeal  abscesses,-  55,  230; 
lymphacic,  syphilitic,  tuberculous, 
2*30 

Rhachitis,  91,  152,  185;  acute,  186; 
atelactasis,  1S8;  and  adenitis,  190; 
and  laryngismus  stridulus,  189, 
403;  and  tetany,  189;  blood  find- 
ings in,  190;  bones  in,  187,  192; 
craniotabes,  191 ;  deformities  in, 
188;  dentition  in,  188;  diagnosis 
of,  192;  diastasis  in,  160;  diet, 
193;  etiology,  185;  epiphyses,  188, 
191 ;  fetal,  1S6  ;  Harrison's  groove, 
1S8;  late,  186;  pathology,  186; 
prognosis,  192 ;  pseudoparalysis  in, 
191 ;  rosary,  191 ;  spinal  curva- 
tures, 189;  splenic  enlargement  in, 
190,  4S8;  tendency  to  catarrh  in, 
189,  327;  time  of  occurrence,  186; 
treatment,  193 

Rheumatism,  628;  blood  in,  630;  causes 
of  endocarditis,  208 ;  chorea  in, 
408,  630;  diagnosis,  629,  630;  ex- 
citing cause  of,  628;  heredity  in, 
628;  treatment,  631 

Rhinitis,  311 ;  contagiousness,  311 ; 
symptoms,  311;'  treatment,  313. 
Atrophic,  312;  chronic,  312; 
treatment,  314.  Effects  of,  312; 
membranous,   315 ;   syphilitic,   316 


Ribs,  at  birth,  27 
Rice-water,  <i!2 
Richmond,  104,    113 
Rickets,  L32,  185 
Riga's  disease,  203 
Kingworiu,   (311 
Rivinus,  notch  of,  21,  46 
Roberts,   141 
Rodagen,  497 
Rosary,  rhachitic,  191 
Rotch,  93,  99,  113,  114 
Rotheln,  554 
Round-worms,  269 
Rous  and  Lannois,  486 
Rubefacients,    648 
Rubella,  554 
Rubeola,  549 
Russell,  93,  113 

S 

Sachs,  461 

Saddle  nose,  312,  589 

Saliva,  72,  74,  136 ;  at  birth,  66 

Salivary  glands,  at  birth,  66 

Salivation  in  glossitis,  202 

Salkowski,  127 

Salts,  effects  of  deficiency,  92;  human 
milk,  table  of,  93;  of  breast  milk, 
91,  92;  of  milk,  calcium  phos- 
phate, 91 ;  iron,  91 ;  potassium  car- 
bonate, chloride,  sulphate,  91; 
sodium  chloride,  91 

Sarcoma  of  ear,  540 

Sauglingsalter,  42 

Scabies,  617 

Scanning  speech,  472;  in  paretic 
dementia,  462 

Scapula,  at  birth,  25 

Scarlatina  hemorrhagica,  544;  ma- 
ligna, 544,  546 

Scarlet  fever,  541 ;  blood  in,  544 ;  com- 
plications, 545;  deaf  mutism,  545 
diagnosis,   546;   etiology,   541;   in 
infancy,      542;      nephritis.      545 
otitis,    545;    prognosis,   546:    sine 
angina,     erupt  ionc,     febre,     544 
sources  of  infection,  542;  suscep 
tibility.      542 :      symptoms,      ;Ti43 
throat     lesions,     545;     treatment, 
547;  types,  544 


666 


INDEX 


Schafer,  94 

Schcenlein's  disease,  509 

Sclerema  neonatorum,  173;  tempera- 
ture in,  173 

Scleroderma,  621 

Scorbutus,  132,  195;  age  of  occur- 
rence, 197;  associated  with  rickets, 
197 ;  diagnosis,  198 ;  exophthalmus 
in,  535;  increased  frequency,  196; 
prognosis,  199;  symptoms,  197; 
treatment,  198;  urine,  197 

Scrofula,  480 

Scurvy,  infantile,  195;  complicating 
rickets,  193 

Seborrhcea,  605 

Seder's  solution,  646 

Sensation,  72 

Senses,  development  of,  71;  special,  at 
birth,  69 

Sensorial  idiots,  459 

Septic  thrombosis,  435 

Septum  of  nose,  47 

Serum  therapy,  498,  547,  573 

Sexual  perversion,  418 

Shiga's  bacillus,  252 

"  Shingles,"  613 

Shoe,  orthopaedic,  134 

Sick-room,   hygiene    of,    633 

Siegfried,  92,  126 

Sight,  at  birth,  69;  development  of, 
71 

Signs,  Babinski's,  423,  474;  Broad- 
bent's,  309;  Chvostek's,  401; 
Erb's,  401;  Friedreich's,  309; 
Kernig's,  424;  Koplick's,  550; 
Macewen's,  423 ;  Oppenheim's, 
475;  Squire's,  424;  Trousseau's, 
401 

Simola  mixture,  modified,  648 

Skin,  blood  supply  of,  68;  care  of,  68; 
diseases  of,  604;  constitutional 
causes  of  diseases,  604 ;  glandular 
activity   of,   68;   of  new-born,   17 

Skull,  18;  at  birth,  20;  fractures,  20 

Sleep  in  infancy,  137 

Slyke,  von,  113 

Smallpox,  555;  modified,  557 

Smith,   E.  E.,   131 

Sodium  bicarbonate,  115,  117;  chlo- 
ride, 91;  citrate,  129 

Soor,  209 


"  Soother,"  228 

Sore  mouth,  canker,  207;  putrid,  210 

Southworth,  74 

Soxhlet,   117 

Spasm,  habit,  411 

Spasms,  394 

Spasmus  nutans,  412 

Spasticity,  451 

Specific  gravity  of  human  milk,  94;  of 
milk,  determination  of,  105 

Speech,  defects  of,  415;  development 
of,  72 

Spencer,  141 

Spermatic  cord,  at  birth,  40;  compo- 
sition, 40 

Spina  bifida,   25,   153 

Spinal  caries,  511;  diagnosis,  513; 
symptoms,  512;  treatment,  514 

Spinal  cord,  at  birth,  41;  cystic  tu- 
mors, 154;  growth  of,  60;  mal- 
formations, 153;  ratio  to  body 
weight,  60 ;  weight  at  birth,  60 

Spinal  curvatures,  144 

Spinal  fluid  in  meningitis,  427 

Spina  ventosa,  518,  521;  pedarthro- 
cace,  518 

Spleen,  at  birth,  37;  disorders  of,  487; 
enlarged,  178,  300,  488,  580,  583; 
etiology,  488;  functions,  487;  in 
malaria,  583;  in  syphilis,  587;  in 
typhoid,  580;  palpability,  37; 
pecularities,  58;  rupture,  488; 
supernumerary,  37;  tumors,  488 

Splenectomy,  487 

Splenic  anaemia,  489 

Splenomegalia,  489 

Spondylitis,    511 

Sponge  bath,  638 

Spotted  fever,  426 

Sprays,  646 

Squamopetrosal  suture,  21,  46 

Squint,  535 

Squire's  sign,  424 

Stammering,  416 

Standing,   72 

Starch  in  feeding,  130 

Starr,  113 

Starting  pains,  512 

Starvation,  132 

Status  epilepticus,  369;  lymphaticus, 
481 


i.\i)i:\ 


»;.;; 


Steapsin,  67 

Stenosis  of  pylorus,  159,  240 

Stephenson,   141 

Sterilization,  117 

Stem,  Heinrich,  (524 

Sterno-mastoid  hematoma,  157 

Sternuni,  at  birth,  27 

Stigmata  of  degeneration,  157,  452 

Still's  disease,  519 

Stomach,     absorption     from,     73; 

birth,  .'>•">;  function  of,  at  birth, 
66;  capacity  of,  35;  capacity  of, 
in  infancy,  55;  development  of, 
55,  73;  digestion  in,  73,  75;  dila- 
tation, 401 ;  functions  of,  73 ;  lym- 
phoid tissue,  35,  55 ;  position  of,  55 

Stomatitis,  206;  aphthosa,  207;  eatar- 
rhalis,  206;   follicular,  207;   gan- 
grenosa,   212;    gonorrhceal,    213 
herpetica,  207;  membranosa,  213 
mycetogenie,    209;    mycosa,    209 
parasitic,  209;  ulcerosa,  210;  ves- 
icular, 207 

Stools,  green,  67;  in  infancy,  67,  73, 
250 

Strabismus,  535 

Stridor,  congenital  laryngeal,  318 

Strophulus,  610 

Struma,  480 

Strychnia  in  diphtheria,  574 

Stuttering,  416 

Stye,  525 

Stypticin,  508 

Subdural  hemorrhages,  at  birth,  41 

Substitute  feeding,   106 

Sucking  pads,  23,  55,  86 

Suckling,  86;  asepsis,  87;  control  of, 
88 ;  duration  of,  87,  89 ;  effects  of 
irregular,  87;  frequency  of,  87; 
hasty,  89;  influence  of  mother 
during,  88;  rules  for,  87,  88,  89; 
too  frequent,  effects  on  child, 
88,  98 

Sudamina,  610 

Sudden  death,  481;  in  enlarged  thy- 
mus, 401 

Sugar  of  milk,  91,  93 

Sulphur.  92 

Sunlight,  83 

Sunstroke,  432 


Suprarenale,  at  birl 
Sutures,  lit.  21,  16 

Sword  leu.  521 

Symblepharon,  532 

Synovitis,  511;  acute  purulent,  522; 
tuberculous,  51 7 

Syphilis,  285,  472.  5s."> ;  acquired,  5S5 ; 
arthritis  in,  521;  hereditary,  585; 
deafness  in  hereditary,  590;  de- 
mentia, 4(12;  diagnosis,  586,  590; 
infantilism,  590;  late,  5S9;  lesions, 
pathology,  pemphigus,  5S(j ;  pro- 
phylaxis, 591;  snuffles,  588; 
spleen,  488;  symptoms,  588;  teeth 
in,  205,  586,  .:>!>0;  treatment,  591; 
transmission,  mode  of,  585 

Syphilitic  diseases  of  bones  and  joints, 
520;  pseudoparalysis,  520,  589 

Syringomyelia,  153,  471;  symptoms, 
472 


Tabes  dorsalis,  474 

Table,  for  home  modification  of  milk, 
119 ;  Connor's,  123 ;  Gurler's,  120 ; 
Ladd's,  119;  of  per  cent,  of  fat 
and  cream,  119 

TacJie  cerebrate,  423 

Tachycardia,  293,  419,  497 

Taenia  elliptica,  269 ;  mediocanellata, 
269;  solium,  269 

Talipes,  155,  473;  in  spinal  paralysis, 
470 

Tapeworm,  beef,  269;  pork,  269; 
treatment,  272 

Tapping  in  hernia  cerebri,  151 

Tarnier,  146 

Taste,  at  birth,  69;  development,  71 

Tears,  72 

Technique  of  bottle  feeding,  124 

Teeth,  care  of,  206;  effects  of  mal- 
nutrition on,  205;  eruption  of,  50; 
grooved,  205;  permanent  develop- 
ment of,  50;  syphilitic.  205.  5S6, 
590;  table  of  eruption,  51;  tem- 
porary, development  of,  49;  char- 
acteristics of,  49 

Temperature,  at  birth.  64;  effects  of 
lowering,  SI ;  elevation  of,  72 ; 
importance   of   even    maintenance 


668 


INDEX 


in  new-born,  64;  in  sclerema,  173; 
normal,  variations  in,  64;  sub- 
normal variations  in,  64;  sub- 
normal,   72 

Testicles,  at  birth,  40;  development  and 
descent  of,  40;  undescended,  392 

Tetanilla,  401 

Tetanus  neonatorum,  179;  nasal  feed- 
ing in,  179 

Tetany,  401 

Therapeutic  suggestions,  635 

Thermic   fever,   432 

Thermo-anassthesia,  472 

Thermometer,  bath,  79 

Thiersch's    grafts,    526 

Thomsen's   disease,   404 

Thorax,  at  birth,  27;  cartilage  in,  27; 
changes  in,  51 ;  diameters,  51 

Thread-worms,  269 

Thrombosis  of  cranial  sinuses,  434; 
etiology,  435;  prophylaxis,  436; 
symptoms,  435 

Thrush,  209 

Thumb  sucking,  effect  on  jaw,  228; 
prevention  of,  81 

Thymus,  cause  of  sudden  death,  481, 
491 ;  changes  in,  54 ;  disorders  of, 
491;  enlarged,  294,  491;  secretion 
of,  491 ;  gland,  at  birth,  33 

Thyroid,  33 

Thyroid,  accessory,  492;  blood  supply, 
33,  492;  development  of,  54;  dis- 
orders of,  492 ;  extract,  effect  of , 
492,  495;  extract  in  cretinism, 
495;  transplantation,  492 

Tic  convulsif,  411;  facial,  411 

Tinea  favosa,  616;  treatment  of,  616; 
trichophytina,  614 

Tongue,  at  birth,  23;  cysts,  201;  dis- 
eases of,  201;  geographic,  203; 
hypertrophy,  201;  infant,  55;  in- 
flammation, 202;  -tie,  204,  415; 
ulcer,  203 

Tonsillitis,  acute,  215 ;  and  chorea,  409 ; 
chronic,  219;  chronic,  with 
adenoids  of  nasopharynx,  219;  in- 
fectious nature,  217;  lacunar, 
217;  phlegmonous,  216;  endocar- 
ditis, 216 ;  pseudomembranous, 
219;  relation  to  other  infections, 


215;  rheumatic,  218;  suppurative, 
216;  ulceromembranous,  220 

Tonsil,  Luschka's,  48 

Tonsils,   55 

Torticollis,  in  hysteria,  406;  in  rheu- 

Trachea,  bifurcation  of,  52;  location 
matism,  629 

Touch,  at  birth,  69 

of,     28;     pseudomembrane,     326; 
size  of,  at  birth,  28 

Tracheitis,  326;  diphtheritic,  326 

Trachoma,  528 

Tracy,  134 

Transplantation,  of  nerves,  of  ten- 
dons, 471 

Trauma,  as  cause  of  insanity,  464 

Trichiasis,  524 

Tricophyton  fungus,  614 

Tricuspid  valve  lesions,  299,  301 

"  Trident  hand,"  165 

Trousseau's  sign,  401 

Truss,  woollen,  161 

Trypsin,  67;  action  of,  74 

Tubbing,   638 

Tuberculosis,  285,  592;  abdominal, 
599;  symptoms,  597.  Abscesses 
in,  597;  and  Addison's  disease, 
490 ;  and  influenza,  564 ;  blood  find- 
ings in,  597;  diagnosis,  597;  fre- 
quency, 592;  general  treatment, 
602;  glandular,  593,  598;  diag- 
nosis of  glandular,  599;  symp- 
toms of  glandular,  598.  Heredity 
in,  593;  marasmic,  595;  miliary, 
595;  mode  of  infection,  -593;  of 
larynx,  321;  of  pancreas,  288;  of 
the  brain,  597;  pathology,  593; 
peritoneal,  600;  C.  animal  inocu- 
lation in,  601 ;  diagnosis  of,  601. 
Pulmonary,  594;  spleen  in,  488; 
symptoms  and  signs,  596;  treat- 
ment, 602;  tuberculin  in,  597; 
tumors  of  cerebellum,  439 

Tuberculous,  adenitis,  598;  portals  of 
infection,  592,  593,  598;  ulcers, 
599 

Tumors,  of  brain,  436 ;  cerebellum, 
438;  crura  cerebri,  439;  ear,  540; 
larynx,  324;  liver,  287;  spinal 
cord,  471 


[NDEX 


669 


Tussis  convulsive/,  -~>f >  1 

Tympanic,  cavity,  21;  membrane,  21 

Typhoid  fever,  578;  and  meningitis, 
580;  blood,  diagnosis,  580;  eti- 
ology, 57S;  fetal,  579;  infantile, 
peculiarities  of,  579;  intestinal 
lesion,  579;  modes  of  infection, 
578;  prognosis,  581;  susceptibil- 
ity, 579;  symptoms,  580;  treat- 
ment, 581 

Tyrotoxicon,  251 

u 

Ulceration  of  rectum,  27S 

Ulcerative  stomatitis,  endemic,  210; 
Vincent's  spirillum,  210,  221 

Ulcer,  of  intestine  in  tuberculosis,  599; 
in  typhoid,  579 ;  of  stomach,  213 ; 
treatment,  244;  syphilitic,  590; 
in  tuberculous  adenitis,  598 

Umbilical  cord,  34;  separation  of,  68 

Umbilicus,  defects  of,  160;  tumors  of, 
159 

Uncinaria  Americana,  269 

Undescended   testicle,   392 

Ureters,  anomalies  of,  369;  double,  369 

Urethra,  at  birth,  40;  imperforate,  163 

Urethritis,  gonorrhceal,  3S5 ;  simple, 
384 ;  specific,  3S5 ;  treatment,  385 

Uric  acid,  90,  378;  at  birth,  67 

Uricacidosis,  372 

Urine,  at  birth,  67;  characteristics  of, 
67,  73;  collection  of,  168;  com- 
position of,  67;  incontinence  of, 
390;  in  infancy,  73;  inorganic 
salts  in,  73 ;  quantity  of,  67,  73 ; 
retention  of,  366;  specific  grav- 
ity, 73 

Urticaria,  611;  factitia.  612:  in  asthma, 
337;  treatment.  G12 

Uterus,  at  birth.  41;  growth  of,  59; 
location    and    size,    41 

Uvula,  elongation  of,  222 

Uvulitis,   222 

V 

Vaccination,  557 

Vaccinia,  550 

Vagina,  atresia  of,  163 


Vaginal  discharge,  68, 

Vaginalitis,  393 

Valvular  disease,  298 

Yanderslice,  129 

Van   Noorden,  ()27 

Van  Slyke,  71.  92,  113 

Vapor  bath,  639 

Variola,  555;  diagnosis,  556;  exan- 
theni,   7)7)7)\    rash,   ->-~>7) 

Varioloid,  557 

Ventilation,  633 

Vernix   easeosa,   17,   69 

Verruca,  622 

Vertebrae,   diseases  of,  511 

Vertebral  column,  at  birth,  24;  curva- 
tures, 51 ;  development,  51 

Vicious  attitudes,  144 

Vierodt,   141 

Vincent's  angina,  210,  220 

Volvulus,  274 

Vomiting.  237;  cyclic,  238;  in.  ear  dis- 
ease, 540;  obstructive,  237;  of 
indigestion,  237;  projectile,  423; 
recurrent.  238;  reflex,  238;  ster- 
coraceous,  237;   toxaemia,   238 

Von  Jaksch,  506 

Vulvo-vaginitis.  complications,  387; 
simple,  386;  specific,  3S6;  treat- 
ment, 388 

W 

Wadsworth,  348 

Walking,  72,  134 

"Warts,"  622 

Wasting,  182 

Water.  Infant's  need  of.  89.  92 

"  Water-hammer  "  pulse,  301 

Water  on  brain,  443 

Weaning,  indications  for,  106;  substi- 
tute food  in,  107 

Weight,  at  birth,  17;  charts,  43;  in- 
crease in  calves.  111 ;  in  infants, 
111 ;    loss    of.    in    new-born,    S6 

Werlhof's  disease.  509 

Wescott's  chart,  122 

Wet-nurse.    108;    selection.   108 

Whey.  128,  644:  and  cream  mixtures, 
119;  proteids,  92.  115.  12S 

White  swelling.  517 

Whole  milk.   129 


670 


INDEX 


Whooping-cough,  561 
Widal's  reaction,  579 
WinckeFs  disease,  180 
Wittmaack,  92 
Woll's  rule,  104 
Worms,  268 
Wright,  129 
Wrist-drop,  479 
Wroblewski,  126 


Xeroderma  pigmentosum,  622 
X-ray,  in  diagnosis  of  calculi,  379;  in 
examination  of  children,  168;  in 
the    treatment    of    Hodgkin's   dis- 
ease, 487 

Z 

Zoster,  614 


